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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 09/10/2026
Date Signed: 09/10/2026 12:23:38 PM

Substantiated


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
10/30/2024 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241030154135
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: 61DATE:
09/10/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Denise GilroyTIME COMPLETED:
08:30 AM
ALLEGATION(S):
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Facility staff failed to notify responsible party of incident timely
Facility staff failed to observe a resident’s change in condition
Facility staff did not timely allow resident back into the facility
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Edward Kim for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPAs met with Staff #1 (S1) Denise Gilroy and explained the reason for today’s inspection.

The investigation into the allegations that facility staff failed to notify responsible party of incident timely, facility staff failed to observe a resident’s change in condition, and facility staff did not timely allow resident back into the facility revealed the following: During the course of the investigation, LPA Haddad inspected the facility, interviewed witnesses, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s staff schedule.

Regarding the allegation that facility staff failed to notify responsible party of incident timely: it was alleged that on October 29, 2024, Resident #1 (R1) experienced a medical emergency and was taken to the hospital, but the resident’s responsible party was not notified timely.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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 4
Control Number 22-AS-20241030154135
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: 09/10/2026
NARRATIVE
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Per R1’s responsible party, the incident occurred around 7:00PM and they were notified around 9:50PM. However, the facility was unable to provide an incident report for this incident, and no such incident reports were received at the Orange County Regional Office (OCRO), meaning no written report of the incident was provided to R1’s responsible party or the OCRO as required.

Regarding the allegation that facility staff failed to observe a resident’s change in condition: it was alleged that a resident experienced a medical emergency and was lying down on the ground in the activity room, but the resident’s condition was not noticed by facility staff and was instead noticed by a firefighter and police officer who happened to be present. Per R1’s responsible party, R1 is deaf and needs close supervision, and when the first responders assessed R1, R1’s blood pressure was very low necessitating emergency transfer to a hospital. LPA Haddad interviewed one witness who corroborated that this incident occurred as reported, stating the fire department had been called for another resident, first responders found R1 having a medical emergency unnoticed by staff, and questioned staff as to how R1’s medical emergency could have gone unnoticed. Per witness statement, R1 should have been in memory care but during this incident was unsupervised in the second-floor activity area and slid out of their wheelchair because no staff were there supervising them.

Regarding the allegation that facility staff did not timely allow resident back into the facility: it was alleged that the front desk is not staffed in the afternoons so there is no staff available to let residents back into the facility, which resulted in residents waiting 15 or 30 minutes at the front door waiting to be let back into the facility. LPA Haddad reviewed the facility’s staff schedule which does not include a section for the reception desk. LPA Haddad interviewed one witness who corroborated that the reception desk is not well staffed in the afternoons and evenings and multiple residents and first responders have had difficulty getting into the building because of this.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20241030154135
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: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87464(f)(1)
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87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by:
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The facility is now closed.
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Based on interview, the facility did not provide care and supervision to R1 when they had a fall and medical emergency necessitating hospitalization unnoticed by staff, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED
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Type A
09/11/2026
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents in All Facilities (a) … (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... This requirement was not met as evidenced by:
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The facility is now closed.
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Based on interview, the facility did not ensure residents could depart and return to the facility by making residents wait outside long periods to be let back in, which poses an immediate personal rights risk to persons in care.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20241030154135
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: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2026
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident… (D) Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:
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The facility is now closed.
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Based on documents and interviews, the facility did not provide a written report to R1’s responsible party or the OCRO of R1’s incident, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4