306090049-9-11-2026-22-AS-LMOA-DYD2G5-20260928172233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 09/11/2026
Date Signed: 09/11/2026 10:51:16 AM

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
07/03/2025 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250703085114

FACILITY NAME:	GRACE RETIREMENT VILLAGE		FACILITY NUMBER:	306090049
ADMINISTRATOR:	MICHELLE SONG		FACILITY TYPE:	740
ADDRESS:	1100 E. WHITTIER BLVD.		TELEPHONE:	(562) 694-6515
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	340	CENSUS: 58	DATE:	09/11/2026
		UNANNOUNCED	TIME BEGAN:	07:46 AM
MET WITH:	Denise Gilroy		TIME COMPLETED:	08:30 AM

ALLEGATION(S):

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Neglect/lack of supervision resulting in resident being struck by a vehicle and hospitalized.
Neglect/lack of supervision resulting resident to wander.

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.

During the course of the investigation, Department staff inspected the facility, interviewed Administrator (AD) Michelle Song, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, a Police Department Report, and Resident #1’s (R1) hospital medical records. The investigation into the allegations of neglect/lack of supervision resulting in resident being struck by a vehicle and hospitalized and Neglect/lack of supervision resulting resident to wander revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250703085114

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: 09/11/2026

NARRATIVE

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R1 was brought to the facility by two family members on July 1, 2025, at around 3:55PM per interview with AD. R1’s family advised AD that R1 had a history of Dementia but did not bring a completed physician’s report for R1. R1 was assigned to a room in assisted living and some of their personal belongings were placed in the room. Around 9:50PM, AD received a call from facility staff who reported that R1 had been in an accident and the police were at the facility. AD spoke with the police who reported that R1 had been hit by a car and was taken to the hospital. Hospital medical records obtained revealed R1 suffered several injuries including diagnosis of loss of consciousness, right subdural hematoma and subarachnoid hemorrhage, parafalcine hemorrhage versus meningioma, T11 compression fracture, L2 vertebral body compression deformity, S3 sacral fracture with presacral hematoma, and bruising and abrasions.
Per interviews conducted with facility staff, R1’s family was with R1 at the facility until 7:30PM. After that time R1 was seen walking near the entrance of the facility and told staff they were waiting for their family to return. The front receptionist reported leaving at 9:00PM and had advised caregivers R1 was near the entrance. Per Police Report obtained, police responded to the scene on July 1, 2025, at 9:52PM after R1 was struck by a car.

AD stated that facility staff did not notice R1 leave the facility, and this was only discovered after the police arrived at the facility. AD stated they had left the facility a little after 5:00PM. Per interview conducted with AD, AD reported assisted living residents can leave the facility freely and the door is not locked. They further stated although R1’s family had reported that R1 had some Dementia, there was no physician’s report completed to determine whether R1 needed memory care or if they were authorized by their physician to leave unassisted. AD stated they had conducted an assessment of R1 prior to admission but did not document the results. AD further stated they did not know R1 was staying the night at the facility as R1 had arrived late in the day and they had told R1’s family that R1 could not be admitted without a physician’s report. When asked why they allowed R1’s family to move R1’s personal belongings into R1’s room, AD stated that it was for the future and they expected the family to come back the following day with the proper paperwork completed. Per AD, an admission agreement had been completed, but no money was exchanged. When interviewed, R1’s responsible party confirmed that they were going to move R1 in that night. R1’s responsible party saw that the facility had staff to look after R1 and had been told by AD that R1 would be looked after and taken care of. R1’s responsible party was unable to confirm whether R1 understood they were now going to be living at the facility and stated R1 kept trying to follow them out of the facility but was redirected back to their room. R1’s family reported that following the accident, R1 needed rehabilitation for two months and is unable to communicate as well as they previously could.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20250703085114

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: 09/11/2026

NARRATIVE

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Although AD claims R1 was not supposed to stay the night at the facility, facility staff treated R1 like the other assisted living residents, which included checking on R1; assigning them a room; and completing an admission agreement. However, the supervision provided was insufficient to meet R1’s wandering needs, resulting in R1 leaving the facility, getting hit by a car, and sustaining fractures and other serious injuries.

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. Immediate civil penalties are being assessed. See LIC421IM.

A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f).

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: 09/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20250703085114

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: 09/11/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/12/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility is now closed.
	8 9 10 11 12 13 14	Based on interviews and documents, the licensee did not ensure R1 received care and supervision when they wandered out of the facility and were hit by a car resulting in fractures, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 09/11/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026

LIC9099 (FAS) - (06/04)

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