Grace Retirement Village

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted and granted entry by staff. LPA spoke with Michelle Song, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included resident file review, tour of the physical plant of the facility and interviews conducted. It is alleged that memory care residents are not being showered. Record review reflects that facility uses a schedule as well as a shower body check from that caregivers use when showering the residents. The shower schedule reflects two shower schedules for morning and evening showers. Schedule and log reflect the residents in memory care that received showers and the time. Interview with 6 of 6 residents Continued on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, April 22, 2025 · control 22-AS-20241223122921

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on April 23, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Michelle Song. LPA explained the reason for the visit. This Department has investigated the complaint alleging that excluded person is operating the facility. Regarding the allegation the following was revealed: During the course of the interviews one of fourteenth individuals interviewed confirmed the allegations. During the course of the investigation LPA reviewed documents including the Licensing Information System (LIS) Facility Personnel Report Summary dated May 02, 2024. During the subsequent visit on April 11, 2025, LPA reviewed the Guardian Employee Roster dated April 10, 2025. Per LIS Facility Personnel Report Summary and Guardian Employee Roster, Staff 1 (S1) is not associated to the facility. During the course of the interviews with resideRead the full finding— CDSS inspection report, April 22, 2025 · control 22-AS-20240423112858

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA Tirre was greeted and granted entry into the facility by Administrator Michelle Song and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Los Angeles Community Hospital Records. The purpose of today’s visit is to follow up on an investigation conducted by the Department regarding the above allegation. The investigation conducted revealed the following: Resident 1 (R1) was admitted to the facility on May 26, 2023. Per physician report dated June 07, 2023, R1 has a primary diagnosis of hypertension with no cognitive impairments. R1 is further listed as having a diagnosis of osteoporosis and able to communicate needs. On July 17, 2023, R1 was admitted to Los Angeles Community Hospital at 9:47 PM, after infoRead the full finding— CDSS inspection report, April 15, 2025 · control 22-AS-20230718165749

Licensing Program Analyst (LPA) Jenifer Tirre met with Administrator Michelle Song for the purpose of delivering findings for the above allegations. The investigation consisted of the following: On October 5, 2023, the department toured the facility, obtained records, interviewed staff and witnesses. Based on records review, R1 was admitted to the facility on May 26, 2023. R1 is ambulatory and uses a walker, and no history of skin condition or breakdown according to physician’s report dated August 23, 2023. R1’s appraisal/needs and services plan dated August 23, 2023, indicates R1 uses a walker to ambulate, no limitation when transferring to bed, no disorientation, and occasionally incontinent. The department interviewed four staff (S1, S2, S3, S4). Medication technician (S1) stated caregivers reported to S4, a Licensed Vocational Nurse (LVN) that R1 has a sore on the back on September 15, 2023. Three staff (S1, S2, S3) stated they observed redness, a rash, or a small “red spot” at R1’Read the full finding— CDSS inspection report, April 15, 2025 · control 22-AS-20231004105837

Regarding the allegation: Staff member did not treat residents with dignity and respect 10 of 11 individuals denied the compliant allegation. During the investigation it was discovered the incident involving the police arriving at the facility was not caused or related to (S3). It is unclear exactly who the police were called on, but the police were not called because of a facility staff member or a facility resident. The police were called on someone visiting one of the residents or attempting to visit one of the residents. According to Staff 2 (S2) someone came to visit Resident 1 (R1) and the person arrived with an attitude. S2 explained that when the person was asked to sign in, the person refused, and the person was saying a lot of “F” words. S2 said the person was yelling and yelling, so S2 called 911 twice. S2 said R1’s family was also contacted. When a family member of R1 arrived at the facility, the family member of R1 had the person who was attempted to visit, arrested. ContiRead the full finding— CDSS inspection report, April 14, 2025 · control 22-AS-20240711144555

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to complete the investigation into the allegation above. During the visit LPA Haley conducted, interviews, collected additional documents and toured the facility to make observations. The complaint investigation consisted of interviews with 11 individuals, including interviews with facility residents and staff. Regarding the allegation: Staff member handles residents in a rough manner 10 of 11 individuals denied the complaint allegation. Staff 1 (S1) denied the allegation and added that Staff (3) is loved by the residents and added that, S3 is a good caregiver. Staff 4 (S4) said the same thing when specifically asked about S3. According to S4, S3 treats the residents good and some of the resident love S3. S4 added, S3’s voice is loud, but that’s just S3’s personality. S3 is not yelling. Further, during interviews with S4 and Staff 5 (S5) both said they would make a report if they ever witness a resident being handleRead the full finding— CDSS inspection report, April 14, 2025 · control 22-AS-20240711144555

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. The investigation into the allegations that facility staff did not obtain timely medical care for resident, facility staff did not ensure that resident was administered their medication(s) as prescribed, facility staff offered oxygen to resident without a doctor's order, and facility staff failed to notify responsible party of injury revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed witnesses and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Physician’s Report dated February 28, 2024, R1’s Primary Care Medical Records, R1’s Home Health Medical Records, a facility communicationRead the full finding— CDSS inspection report, March 26, 2025 · control 22-AS-20240624114306

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Michelle Song, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff at the facility do not have a criminal record clearance revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and staff schedule. CONTINUED SubstantiatedRead the full finding— CDSS inspection report, March 6, 2025 · control 22-AS-20250303114031

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with (AD) Michelle Song and explained the reason for today’s inspection. The investigation into the allegation that the facility is malodorous revealed the following: During the course of the investigation, LPA inspected the facility, interviewed witnesses, and obtained and reviewed copies of the resident roster and staff roster. It was alleged that nearly every resident room has the “overwhelming smell of urine and feces.” On October 24, 2024, and November 4, 2024, LPA inspected the facility, including 35 resident rooms, and conducted health and safety checks on approximately 65 residents and LPA’s observations corroborated this allegation. LPA noted mild bad odors, including urine and feces odors, in the memory care common area, hallway, and resident rooms. LPA did not note anRead the full finding— CDSS inspection report, November 6, 2024 · control 22-AS-20241023161245

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Administrator Michelle Song and explained the reason for the visit. LPA and the Administrator toured the facility including the kitchen. The investigation into the allegation, facility staff served expired food to residents revealed the following. LPA toured the kitchen. LPA observed the kitchen is clean and organized. LPA observed the refrigerators and freezers are kept at the required temperatures. LPA inspected the stored food supplies. LPA observed 49 boxes of cereal stored in the kitchen are expired. LPA verified with the Administrator who agreed 49 boxes of cereal are expired. The preponderance of evidence standard has been met, therefore the allegation is substantiated. The investigation into the allegation facility does not have sufficient night staff to meet residents needs revealed the followiRead the full finding— CDSS inspection report, October 16, 2024 · control 22-AS-20241010093603

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Assistant Administrator (AA) Michelle Song and explained the reason for today’s inspection. The investigation into the allegation that staff did not follow proper food handling techniques revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents, staff, and witnesses, and obtained and reviewed copies of the resident roster and staff roster. Regarding the allegation that staff did not follow proper food handling techniques: it was alleged that a witness observed staff giving one resident’s leftover food that they had started eating but did not finish to another resident because the kitchen had run out of that particular food item. LPA interviewed the witness who identified the staff at issue. LPA interviewed the staff at issue who denied the allegation.Read the full finding— CDSS inspection report, May 15, 2024 · control 22-AS-20240507092306

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Receptionist Joo Eun Ra. LPA explained the reason for the visit. Administrator Assistant (ADA) Anna Jung arrived shortly after. Resident 1 (R1) was admitted to the facility on May 03, 2023. R1’s Physician report dated May 06, 2023, lists R1 as having a diagnosis of Hypertension and Type II Diabetes. R1 is noted as not being able to communicate needs but able to leave the facility unassisted. Four days later R1’s physician report was updated on May 10, 2023, as being able to communicate their needs with a note that said R1 wanted to handle their needs by themselves. During the investigation the Department spoke with the physician listed as completing the physician reports. A true signature was presented by the physician and their attorney. The Department determined the signature presRead the full finding— CDSS inspection report, December 20, 2023 · control 22-AS-20230531150652

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Administrator Assistant Anna Jung and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including the Physician Report (LIC602) dated April 29, 2022, Unusual Incident/Injury Report dated May 1 2022, Appraisal/Needs and Services Plan dated April 29, 2022, for Resident 1 (R1), Personnel Report (LIC500), Resident Roster, Fire Safety Inspection Request dated February 16, 2023 and Plan of Operation related to care of persons with Dementia. The purpose of today’s visit is to deliver the findings regarding the above allegation. The investigation conducted revealed the following: R1 was admitted to the facility officially on April 29, 2022, as per signed admission agRead the full finding— CDSS inspection report, November 9, 2023 · control 22-AS-20220502151946

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings for the complaint received on 6/20/23. LPA arrived at the facility and explained the purpose of today’s visit, was greeted and granted entry by staff on duty. Facility administrator (AD) Erik Doan was notified but was unable to be present during today’s visit. LPA De Perio met with assistant facility administrator Anna Jung. The complaint was investigated by the Department which involved interviews and record review. It is alleged that facility staff did not adequately supervise residents resulting in resident wandering from the facility and sustaining multiple injuries.The investigation revealed that resident (R1) was admitted to the facility on May 4, 2023, of which facility administrator and staff were informed that R1 was a fall risk but not an elopement risk because there was no history of R1 eloping. On May 4, 2023, a discharge summary report was completed by the PasadenaRead the full finding— CDSS inspection report, November 2, 2023 · control 22-AS-20230620133756

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on 05/02/22. LPA was greeted and granted entry into the facility and met with Administrator (AD) Crysel Santos and explained the reason for the visit. This agency has investigated the complaint alleging that facility has inadequate security systems. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: During the investigation LPA reviewed documents including the Fire Safety Inspection Request dated 02/16/22. Per Fire Safety Inspection Request under special conditions, it states Memory Care and delayed egress. LPA also reviewed the Plan of Operation related to care of person with Dementia. Per Plan of Operation all facility exits are equipped with operational auditory alarms if exiting may pose a hazard to residents. During the initial visit on 05/06Read the full finding— CDSS inspection report, September 11, 2023 · control 22-AS-20220502151946

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Receptionist Rachel Chung and explained the reason for the visit. Adminstrator Crystal Santos was present as well. The department received a complaint on 06/02/2023 and LPA Mendivil conducted the initial 10 day visit on 06/07/2023. During the course of the investigation LPA Mendivil interviewed staff and obtained copies of liability insurance certificate. Regarding the allegation the facility does not maintain required liability insurance, the investigation revealed the following: The department received a complaint that the facility does not maintain the required insurance. Based on interviews with Licensee Eric Doan, Licensee was able to provide a copy of the liability insurance certificate. SubstantiatedRead the full finding— CDSS inspection report, August 31, 2023 · control 22-AS-20230602120947

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry to facility by LVN Grace Park and explained the reason for the visit. The department received a complaint on 06/02/2023 and LPA Mendivil conducted an initial visit on 06/07/2023. LPA Mendivil obtained copies of medication administration records, physician’s report and admission agreements. Regarding the allegations Facility failed to administer medication as prescribed and Facility refused resident access to telephone, the investigation revealed the following: It was alleged that Resident 1 (R1) was not receiving their medications and that cell phone access was restricted by the facility. Based on interviews with witnesses it was reported that R1's family retrieved R1's cell phone on 05/31/2023. CONT on LIC 9099-C dated 08/02/2023 UnsubstantiatedRead the full finding— CDSS inspection report, August 2, 2023 · control 22-AS-20230602142710

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on 05/02/22. LPA was greeted and granted entry into the facility and met with Staff Rachel Chung and explained the reason for the visit. Administrator (AD) Erik Doan was notified via telephone. This agency has investigated the complaint alleging that facility is operating understaffed. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Three of eleven individuals interviewed denied the allegation. Five individuals reported that hiring more staff would be helpful and the remaining three individuals were not able to be contacted by LPA. As of 06/19/23 facility reported a total census of eighty-three residents. Records reviewed by LPA Ramirez included the staff schedule. On average there are four caregivers and one medication technician for the morniRead the full finding— CDSS inspection report, August 1, 2023 · control 22-AS-20220502151946

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Rachel Shung and explained the reason for the visit. Grace Park, LVN was present as well. The department received a complaint on 07/06/2023 and the initial 10 day visit was conducted on 07/07/2023. During the course of the invesitgation LPA Mendivil interviewed staff. Regarding the allegation Staff did not release records to resident's responsible party, the invesitgation revealed the following: Based on interviews with witnesses the request was delivered via certified mail on 06/23/2023. Based on interviews with staff there is conflicting information as to who is responsible for sending the documents. Based on iInterview with a witness the documents requested have not been received as of 07/24/2023. CONT on 9099-C dated 07/25/2023 SubstantiatedRead the full finding— CDSS inspection report, July 25, 2023 · control 22-AS-20230706132440

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch 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 by front desk staff after introducing himself and stating the purpose of the visit. Administrator Erik Doan was notified via telephone and arrived later to assist with the visit. On July 6, 2022, LPA Sean Haddad conducted an initial complaint investigation visit at the facility.LPA met with Administrator (AD) Hyo Sook Kim, discussed the purpose of the inspection, and explained the allegations. During the inspection, LPA interviewed AD and requested and reviewed copies of resident roster, staff roster, resident files, and other pertinent records. During a follow-up visit conducted on June 23, 2023, LPA requested resident R1's records kept at the facility after his passing on June 28, 2022. Facility staff was unable to provide the records on that day. CONRead the full finding— CDSS inspection report, July 3, 2023 · control 22-AS-20220629095332

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on 05/31/23. LPA was greeted and granted entry into the facility and met with Administrator (AD) Erik Doan and explained the reason for the visit. This agency has investigated the complaint alleging that staff did not allow resident to have visitors. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Eight of ten individuals interviewed denied the allegation. As for the remaining two individuals, one individual confirmed the allegation and the other could not be interviewed as they were on vacation. During the investigation LPA reviewed documents including the Visitor Sign In/Out Log dated 04/29/23 through 06/18/23. Per Visitor Sign In/Out Log on 05/14/23 a visitor for Resident 1 (R1) sign in at 7:45 AM and sign out at 8:10 AM. On average per dayRead the full finding— CDSS inspection report, June 30, 2023 · control 22-AS-20230531150652

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch 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 by facility staff after introducing himself and stating the purpose of the visit. Facility administrator was notified by telephone and informed of the report. An initial investigation visit was conducted on April 27, 2022. LPA Sean Haddad inspected the facility, interviewed one resident and three staff members. LPA also requested and reviewed copies of resident roster, staff roster, and facility records. Regarding the allegation that Resident went AWOL from the facility, the following has been concluded: On April 17 2022, facility became unable to locate resident R1 at approximately 2:30PM. After being notified of the resident's absence, the facility administrator called the La Habra Police Department. CONTINUED ON FORM LIC9099-C SubstantiatedRead the full finding— CDSS inspection report, June 16, 2023 · control 22-AS-20220418111625

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings in the investigation of the allegation listed above. LPA was greeted and granted entry by nursing staff before explaining the purpose of the visit and listing the allegation. Administrator Erik Doan was notified by telephone and arrived later to assist with the visit. An initial complaint investigation visit was conducted on January 26, 2023. LPA accompanied by then administrator Hyo Sook Kim toured the unit assigned to resident R1. Resident records reviewed and an interview of the caregiver on staff in the early hours of January 18, 2023 was conducted by telephone. Additional interview conducted with facility administrator. A subpoena of medical records from resident R1's trip to the emergency department at UCI Hospital was submitted and records reviewed. Additional witnesses interviews were conducted via telephone. CONTINUED ON FORM LIC909Read the full finding— CDSS inspection report, April 12, 2023 · control 22-AS-20230119153437

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Rachel Shung and explained the reason for the visit. Administrator Monica Kim was available via telephone and later arrived at facility. The department received a complaint on 03/23/2023 and the initial 10 day visit was conducted on 03/27/2023. During the course of the invesitgation LPA Mendivil interviewed staff. Regarding the allegation facility did not release resident records to the legal representative, the invesitgation revealed the following: Based on interviews with the Administrator Monica Kim the facility received a formal request for a resident's documents on 3/21/2023. Based on interviews with staff there is conflicting information as to who is responsible for sending the documents. Interview with a witness reports that the documents are still not received as of 3/27/2023. CONT on 9099-C dated 03/2Read the full finding— CDSS inspection report, March 27, 2023 · control 22-AS-20230323114408