<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 09/17/2026
Date Signed: 09/17/2026 09:48:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2024 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240911154045
FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:340CENSUS: DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
07:38 AM
MET WITH:Denise GilroyTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff is failing to address a scabies outbreak and bed bugs infestation, resulting in multiple residents become injured or infected.
Food service requirements are not met.
Residents are not free to individually contract with their own hospice or home health providers.
Facility staff is forging resident documents.
Licensee is unable to exercise general supervision over the affairs of the facility and to establish policies concerning its operation.
Facility staff failed to provide adequate care and supervision necessary to prevent the occurrence of pressure injuries in multiple residents.
Facility failed to provide adequate care and supervision that resulted in residents’ lacerations.
License engaged in conduct inimical
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry to the facility by staff, LPA introduced themselves and stated the purpose of the visit.

Findings are based upon this investigation which included tour of the facility, facility file review, resident file review and interviews conducted.

It is alleged that facility staff is failing to address a scabies outbreak and bed bugs infestation, resulting in multiple residents become injured or infected. LPA Saborit-Guasch and LPA Mason conducted a joint visit to the facility and observed the following: During the visit, LPAs were unable to clearly identify whether any of the residents allegedly depicted in the photographs provided alongside the original complaint
CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 22-AS-20240911154045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 09/17/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
report were current residents of the facility and to formally identify them as the information provided to the department and/or did not allow licensing staff to do so. None of the twenty or so unidentified residents observed in the memory care common area showed signs of injury comparable with what was being displayed in the photographs provided by the reporting party. A significant number of residents, however, displayed signs consistent with a scabies and/or bed bug infestation, as confirmed by Public Health staff present, with multiple residents actively scratching their skin, acting restless and showing rashes on the visible parts of their arms and legs. LPAs observed displayed signs of itchiness or residents scratching themselves. Record review reflects the department received incident reports on September 13, 2024, that there were residents that displayed skin problems and were sent out to seek medical assistance. It was not verified If the skin problems were a result of scabies.

It is alleged that food service requirements are not met, specifically to facility having expired can goods and food provided are regular American food and Asian food. LPAs conducted a visit on September 12, 2024, April 18, 2025, and August 27, 2026, and conducted a tour of the food storage for the facility. On all visits it was observed facility has a storage room for canned goods and non-perishables. Expiration dates were observed on non-perishables, and it was observed on all visits that there was no expired food. Interview with 3 of 3 staff stated that food delivery is done twice a week, the facility has two available menus from American food to Asian food. The food for the facility is done this was since a majority of the facility is Asian and prefer food from their culture. Since Korean/Asian food is so hard to make that food gets catered in order for the facility to meet the required standards. LPA Martinez on August 27, 2026, toured the facility kitchen and observed food preparation for lunch and cutting veggies, fresh groceries were washed and there was pot on the stove as well. Food prep looked reasonable and within regulations expectations.

It is alleged that residents are not free to individually contract with their own hospice or home health provider, specifically only being assigned to Excellent Care Home Health and Monserrat Hospice. Records revealed that there were residents receiving care for the mentioned provider as well as other hospice and home health providers. Last facility visit conducted there were no residents on records for the mentioned providers. Interview with 2 of 2 staff indicated that there were currently no residents under care with the providers mentioned, but records show that at some point there were residents assigned to those providers. Resident and/or their responsible party has the ability to choice their own provider when requiring services. Interview with 10 of 10 residents stated that facility helps them with the process, but they do not choose what provider
CONTINUED LIC9099-C
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 22-AS-20240911154045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 09/17/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
resident will get services from. Residents stated that they can pick whoever they like to provider services.

It is alleged that facility staff are forging residents’ documentation, specifically physicians’ reports. Record review revealed that LPA Saborit-Guasch reviewed and obtained resident records based on the facility’s current census. The physicians’ reports reviewed were signed and dated by a physician or other qualified medical professional. The reports also contained identifying information and/or stamps associated with the physician’s office. The reviewed documentation did not contain evidence indicating that the signatures or other information on the physicians’ reports had been forged by facility staff. Based on the records reviewed, no evidence was identified to substantiate the allegation that facility staff forged residents’ documentation, specifically physicians’ reports.

It is alleged that licensee is unable to exercise general supervision over the affairs of the facility and to establish policies concerning its operation. However, based on observations made during the multiple visits, the facility was observed to be actively operating and maintaining its day-to-day operations. Care staff were present and providing services to residents, intake records were maintained, and the facility had a Plan of Operation in place outlining the facility’s procedures and operational practices. These observations demonstrate that the facility has established operational processes and staffing procedures to support the ongoing care and supervision of residents.

It is alleged that facility staff failed to provide adequate care and supervision necessary to prevent the occurrence of pressure injuries in multiple residents. LPA Saborit-Guasch conducted facility visits on September 12, 2024, and April 18, 2025, to assess allegations related to the care and supervision provided to residents. On August 27, 2026, LPA Martinez conducted a facility visit to further assess the allegation. During the facility visits, LPAs did not observe any residents with pressure injuries. A review of available facility records did not identify documentation indicating that any current residents had pressure injuries. Additionally, LPA Martinez interviewed 2 of 2 staff members, both of whom stated that there were no residents currently residing at the facility with pressure injuries. Based on observations, record review, and staff interviews conducted during the August 27, 2026, visit, as well as the prior facility visits conducted by LPA Saborit-Guasch on September 12, 2024, and April 18, 2025, no evidence was identified during the investigation to substantiate the allegation that facility staff failed to provide adequate care and supervision necessary to prevent pressure injuries in multiple residents.
CONTINUED ON LIC9099-C
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 22-AS-20240911154045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 09/17/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It is alleged that facility failed to provide adequate care and supervision that resulted in resident's lacerations. LPA Saborit-Guasch conducted facility visits on September 12, 2024, and April 18, 2025, to assess allegations related to the care and supervision provided to residents. On August 27, 2026, LPA Martinez conducted a facility visit to further assess the allegation. During the August 27, 2026 visit, LPA Martinez did not observe any residents with lacerations or visible injuries. A review of available facility records did not identify documentation indicating that current residents had lacerations resulting from inadequate care or supervision. Additionally, LPA Martinez interviewed 2 of 2 staff members, both of whom stated that they were not aware of any current residents having lacerations. Based on observations, record review, and staff interviews conducted during the August 27, 2026 visit, as well as the prior facility visits conducted by LPA Saborit-Guasch on September 12, 2024, and April 18, 2025, no evidence was identified during the investigation to substantiate the allegation that facility staff failed to provide adequate care and supervision resulting in resident lacerations.

It is alleged that the licensee engaged in conduct inimical, specifically involving management acting on behalf of an individual other than the licensed owner. During the investigation, LPA Saborit-Guasch and LPA Martinez reviewed available facility records and conducted observations of the facility’s operations. No records or observations were identified that indicated the current management team was operating the facility on behalf of, or under the direction of, an individual other than the licensed owner. LPA Martinez also interviewed two (2) of two (2) management staff members. Both management staff stated that they had no indication that the facility was being operated on behalf of another individual and stated that they would not continue working at the facility if they became aware that the facility was being operated on behalf of an individual other than the licensed owner. Based on observations, record review, and interviews conducted during the investigation, no evidence was identified to substantiate the allegation that the licensee engaged in conduct inimical by having management act on behalf of an individual other than the licensed owner.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated.

An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2024 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240911154045

FACILITY NAME:GRACE RETIREMENT VILLAGEFACILITY NUMBER:
306090049
ADMINISTRATOR:MICHELLE SONGFACILITY TYPE:
740
ADDRESS:1100 E. WHITTIER BLVD.TELEPHONE:
(562) 694-6515
CITY:LA HABRASTATE:CAZIP CODE:
90631
CAPACITY:340CENSUS: DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
07:38 AM
MET WITH:Denise GilroyTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee is not assuring provision of the required items of furniture in good repair.
Facility co-mingled resident funds with facility funds.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry to the facility by staff, LPA introduced themselves and stated the purpose of the visit.

Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, and trust audit.

It is alleged that the licensee failed to assure the provision of required items of furniture and equipment were maintained in good repair. LPA Saborit-Guasch conducted facility visits on September 12, 2024, and April 18, 2025, to assess the facility’s compliance with applicable requirements. During one of the visits, LPA Saborit-Guasch observed damaged and/or inadequately maintained furniture and fixtures in resident
CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 22-AS-20240911154045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 09/17/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
rooms 103, 104, 105, 106, 110, 114, 224, 233, 263, and 340. Observed conditions included damaged bathroom flooring, broken dressers, a broken wall panel, a bathroom sink containing dirty water, beds without linens, beds without bed frames, a toilet without a cover on the water tank, a bathroom wall with a hole, a mattress placed directly on the floor with the box spring folded up, a broken air conditioner plate, and a bed frame without a mattress. These observations indicate that required furniture, fixtures, and/or equipment in multiple resident rooms were not maintained in good repair and/or were not adequately provided at the time of the visit. Based on the observations made by LPA Saborit-Guasch during the facility visits, the allegation that the licensee failed to assure the provision of required items of furniture in good repair is substantiated.

It is alleged that the facility co-mingled residents’ personal and incidental (P&I) funds with facility funds. A review of the documentation disclosed that the licensee maintains a business bank account into which residents’ rent payments and P&I funds are deposited. The licensee does not maintain a separate trust account for residents. According to Administrator Michelle Song, P&I funds are withdrawn from the business account and provided to the applicable resident, and the facility does not handle or maintain residents’ funds. However, in an email, the Administrator stated that P&I funds belonging to at least one resident reviewed were maintained in the facility office. The Auditor also observed that some of the residents reviewed who received P&I funds had a diagnosis of dementia and/or were documented on their LIC602, Physician’s Report, as being unable to handle their own cash resources. Based on the information reviewed, these residents may require their cash resources to be safeguarded rather than provided directly to them for personal possession. Additionally, when a resident does not have a responsible party available to manage their cash resources, the facility may be responsible for safeguarding those funds in accordance with applicable requirements. Based on the discrepancy between the Administrator’s statements regarding the handling of P&I funds and the documentation indicating that P&I funds for at least one resident were maintained at the facility, concerns were identified regarding the facility’s accounting, safeguarding, and

CONTINUED ON LIC9099-C
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 22-AS-20240911154045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
VISIT DATE: 09/17/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
disbursement of residents’ P&I funds, including whether all residents received the full amount of funds maintained on their behalf. Based on the documentation reviewed, statements obtained, and observations made during the investigation, the allegation that the facility co-mingled residents’ P&I funds with facility funds is substantiated.

During the course of the investigation, there was sufficient evidence to substantiate the allegation of facility failed to report active covid cases. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with facility representative and a copy of this LIC9099 and LIC9099-D, along with a copy of the appeal rights was left at the facility.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 22-AS-20240911154045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRACE RETIREMENT VILLAGE
FACILITY NUMBER: 306090049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2026
Section Cited
CCR
87307(d)(2)
1
2
3
4
5
6
7
Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement was not met as evidenced by: LPAs observations
1
2
3
4
5
6
7
Facility is now closed
8
9
10
11
12
13
14
observed various resident rooms with furnishings broken or incomplete. which poses a potential health risk to persons in care.
8
9
10
11
12
13
14
Type B
09/24/2026
Section Cited
CCR
87217(a)
1
2
3
4
5
6
7
Safeguard of Residents Cash, personal property, and Valuables (a) A licensee shall not be required to handle residents' cash resources. However, if a resident incapable of handling his own cash resources, as documented by the initial or subsequent appraisal, is accepted for care, his cash
1
2
3
4
5
6
7
Facility is now closed
8
9
10
11
12
13
14
 This requirement was not met as evidence by: audit performed details concerns were identified regarding the facility’s accounting, safeguarding, and disbursement of residents’ P&I funds, which poses a potential healthrisk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8