306090049-9-14-2026-22-AS-LMOA-DYD23L-20260928170231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306090049
Report Date: 09/14/2026
Date Signed: 09/14/2026 10:36:15 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
03/13/2025 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250313083618

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: 50	DATE:	09/14/2026
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Denise Gilroy		TIME COMPLETED:	08:30 AM

ALLEGATION(S):

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Licensee did not report incidents

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026

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 6

Control Number 22-AS-20250313083618

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: 09/14/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/15/2026 Section Cited CCR 87211(a)(1)(A)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports…, including, but not limited to… (1) … (A) Death of any resident from any cause regardless of where the death occurred… 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 documents, the licensee did not ensure R1’s death was properly reported to the OCRO other required parties, which poses a potential 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: 09/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 22-AS-20250313083618

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: 09/14/2026

NARRATIVE

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It was alleged that the facility did not properly report R1’s death. LPA Haddad reviewed R1’s death report which indicates R1 passed away on January 11, 2025. However, it was reported that this death report was written on March 5, 2025, and not properly distributed until that date. Based on review of incident reports received in the Orange County Regional Office (OCRO), R1’s death report was never submitted to the OCRO as required.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is 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: 09/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
03/13/2025 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250313083618

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: 50	DATE:	09/14/2026
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Denise Gilroy		TIME COMPLETED:	08:30 AM

ALLEGATION(S):

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Facility staff did not ensure resident’s medical needs were met
Questionable Death

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 Denise Gilroy and explained the reason for today’s inspection.

The investigation into the allegations that facility staff did not ensure resident’s medical needs were met and questionable death revealed the following: During the course of the investigation, LPA Haddad inspected the facility, interviewed staff and witnesses, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) physician’s report dated November 27, 2024, R1’s home health records, R1’s admission agreement, R1’s death report, R1’s death certificate, R1’s appraisal dated November 27, 2024, R1’s hospice records, and R1’s physician orders for life-sustaining treatment (POLST).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 22-AS-20250313083618

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: 09/14/2026

NARRATIVE

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Regarding the allegation that facility staff did not ensure resident’s medical needs were met: it was alleged that on December 17, 2024, R1 was observed with wounds on the left knee and left ear lobe, both with no dressing. Staff #1 (S1) stated the knee wound had been reported two days prior to a nurse on site. Witness #1 (W1), claimed R1’s ear wound was being treated by their doctor, but the facility was unable to provide documents or information regarding the treatment of either of these wounds. It was also noted that R1 did not have an air mattress or half side rails. Interviews with current staff revealed that S1 and W1 are no longer with the facility but confirmed that W1 was R1’s nurse from R1’s home health agency. LPA attempted to interview W1, but W1 refused to provide information. Interviews with current staff did not corroborate that R1 had wounds at the time and did not provide information regarding R1’s mattress or bedrails. R1’s physician’s report dated November 27, 2024, and R1’s home health records do not include any information regarding any wounds or R1’s bed. LPA attempted to interview R1’s family, but was unsuccessful. The information obtained is conflicting.

Regarding the allegation of questionable death: it was alleged that R1 passed away on January 11, 2025, and the facility was unable to provide any information or documents regarding R1’s passing or the care R1 received prior to their passing. Per R1’s admission agreement, R1 was admitted to the facility on March 1, 2022. LPA reviewed R1’s death report which indicates that on January 11, 2025, at 3:00AM, staff found R1 not breathing after R1 had been unconscious for the last two days. R1 passed away due to acute respiratory failure and Alzheimer’s disease, and staff notified R1’s hospice and family. R1’s death certificate indicates that on January 11, 2025, at 3:00AM, R1 passed away from acute respiratory failure with an underlying cause of Alzheimer’s disease. R1’s death was not reported to the coroner. Per R1’s Physician’s Report dated November 27, 2024, R1 had diabetes and dementia, a history of skin breakdown, schizophrenia and anxiety, needed a wheelchair, and was in poor physical health. Per R1’s appraisal dated November 27, 2024, R1 required total care. Per R1’s home health records, R1 was seen by their home health nurse on January 6, 7, and 8, 2025, and was noted to be alert during these visits. R1’s appetite fluctuated between fair and poor. No immediate concerns were noted other than R1’s appetite. R1 was given IV infusions, which R1 stated helped them feel stronger and was encouraged to eat more and drink nutritional supplements. Per R1’s hospice records, R1 was assessed for admission to hospice on January 10, 2025, at 11:00AM, R1 was alert but confused during the assessment, and R1 had diagnoses of metabolic encephalopathy, failure to thrive and debility, Alzheimer’s disease, diabetes, hypothyroidism, schizophrenia, bullae, depression, hyperlipidemia, and anxiety.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 22-AS-20250313083618

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: 09/14/2026

NARRATIVE

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R1’s hospice records indicate R1 had poor appetite and inadequate fluid intake. Caregivers and family were concerned with R1’s food intake, and R1’s disease trajectory was a “saw-toothed decline” including symptom exacerbations and improvement. R1’s hospice records indicate R1 has been refusing food which can cause a medical decline. R1’s family declined aggressive treatment and chose comfort-based treatment instead. Per R1’s POLST, signed by R1’s family on January 10, 2025, R1 was under a do not attempt resuscitation order. Regarding the statement in R1’s death report that R1 had been unconscious for two days before they passed away, LPA obtained another version of the death report with this language removed and R1’s hospice records indicate R1 was alert, not unconscious, less than 24 hours before they passed away. LPA attempted to interview R1’s family, but was unsuccessful. Based on the information obtained, R1 was seen often by medical professionals in the days prior to their death who documented R1’s decline but no concerns about the care R1 was receiving at the facility. Prior to their passing, R1 was assessed to be hospice appropriate and admitted to hospice, with R1’s family involved in the decision, declining aggressive treatment, and signing R1’s POLST, indicating R1’s death was expected and R1’s family agreed with R1’s prognosis and plan of care.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegation are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026

LIC9099 (FAS) - (06/04)

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