Grace Retirement Village

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management visit documenting deficiencies observed during the investigation of complaint 22-AS-20220629095332. On June 23, 2023, LPA conducted a complaint follow-up visit at the facility. LPA requested resident records for resident R1, which facility staff and administrator were unable to locate and provide. LPA agreed to provide licensee with an additional delay to find where the documents were stored and provide them. LPA followed up on this day, July 3, 2023. LPA spoke on the telephone with administrator Erik Doan who admitted that staff and himself had been unsuccessful in their attempts to locate the records, which included reaching out to former administrator Hyo Sook Kim. Former administrator is related to have said that the files should be stored along with the records of discharged and/or deceased residents, as resident R1 passed away at the facility on June 28, 2022. As a result, a type B citation is issued to the facility on the attached form LIC809-D for failure to comply with Section 87506(e) of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were printed and provided to a facility representative.the state’s words, verbatim · CDSS document, Jul 3, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Aug 3, 2023

The California Code of Regulations Section 87506(e) on Resident Records states that "Original records (...) shall be retained for a minimum of three (3) years following termination of service to the resident." This requirement is not met as evidenced by: The records requested by LPA Saborit-Guasch were unsuccessfully searched by facility staff who was eventually unable to provide them altogether. This poses a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jul 3, 2023

Plan of correction: Licensee to train all staff handling resident records of the necessity to maintain complete and accurate records for every person admitted and retain them at the facility for a minimum of three years following termination of service to the resident. A copy of the training's curriculum and attendance will be provided to LPA before the Plan of Correction's due date of August 3, 2023.

Allegation investigated: Staff did not allow resident to have visitors

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 day one to thirteen visitors signed the Visitor Sign In/Out Log between May and June 2023. Continued on LIC9099-C... Unsubstantiated During the initial visit on 06/01/23 and today’s visit LPA observed a sign with the visitation hours posted in the main entrance of the facility. During interviews with staff and residents it was reported that family is allowed to visit any time and/or that there are no restrictions when it comes to family visiting. During the course of the interviews AD stated that friends and family are allowed to visit from 8:00 AM-5:00 PM. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Therefore, the allegation has been deemed to be UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred. LPA Ramirez conducted an exit interview with AD Doan, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 30, 2023 · control 22-AS-20230531150652

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit to deliver amended reports dated 05/06/22 and 06/19/23 for complaint 22-AS-20220502151946 and reports dated 06/01/23 and 06/19/23 for complaint 22-AS-20230531150652. LPA met with Administrator (AD) Erik Doan and explained the purpose of the visit. During the inspection, LPA and AD discussed the previously delivered findings and the amended findings and LPA delivered the amended report. An exit interview was conducted with AD Doan and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Jun 30, 2023

Allegation investigated: Resident went AWOL from the facility. Facility floor is in disrepair.

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 Substantiated CONTINUED FROM FORM LIC9099-A The three outside exit gates were all confirmed to be functioning properly. The two outside gates accessible to residents are kept locked. A third gate only accessible by going through a delayed egress door (and triggering an alarm) is unlocked as a fire exit. It was suggested during the visit that resident R1 may have exited the facility through an unlocked sliding window for a unit outside memory care that leads into the locked outside area. Therefore the allegation is deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED ON FORM LIC9099 After receiving the missing person report, law enforcement conducted a search for the missing resident. Facility staff S1 was informed by a relation of the whereabouts of resident R1 approximately one hour later. Resident was found at a nearby gas station and brought back to the facility. Local law enforcement was notified that resident was no longer missing at this time. Facility administrator stated to LPA Haddad that she had not reported the elopement to the Department because R1 was found so quickly and claimed to not have been aware of the reporting requirements. Administrator however reported the elopement and its resolution to law enforcement and to R1's responsible party. Based on the interview conducted, the allegation is deemed Substantiated, meaning that the preponderance of evidence standard has been met. A Type A citation is issued on the attached form LIC9099-D and civil penalty is assessed per Title 22 regulations. Regarding the allegation that Facility floor is in disrepair, the following has been concluded: During the tour of the physical plant conducted during the initial investigation visit, LPA Haddad observed brand new hardwood floor in the memory care unit. Visual inspection shows the floor is recently installed, however due to a probable installation error, the material bunches up in places and creases up, thus creating a fall hazard. A Type B citation is issued on the attached form LIC9099-D. The floor defects are confirmed to have been corrected since the initial visit, therefore the deficiency is cleared. An exit interview was conducted and a copy of this report along with appeal rights was made and provided to a facility representative.the state’s words, verbatim · CDSS document, Jun 16, 2023 · control 22-AS-20220418111625

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312 · Plan of correction due date: Jun 23, 2023

Health and Safety Code section 1569.312 provides that every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety. Based on interviews conducted, this requirement is not being met as evidenced by the fact that resident R1 was able to leave the facility unattended in spite of being admitted to the secure memory care unit.the state’s words, verbatim · CDSS document, Jun 16, 2023

Plan of correction: Licensee to provide updated training on the importance of securing all ways of ingress and egress into the memory care unit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 16, 2023

California Code of Regulations Section 87303(a) on Maintenance and Operation states that: "The facility shall be clean, safe, sanitary and in good repair at all times." Based on observation conducted at the facility, this requirement is not met as evidenced by: Floor material in the memory care unit bunches up in places and creases up, thus creating a fall hazard.the state’s words, verbatim · CDSS document, Jun 16, 2023

Plan of correction: Licensee to ensure that the flooring in all areas of the facility is safe and in good repair.

Type of visit: Case Management - Other

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting additional interviews for Complaint Control No. 22-AS-20220907180032. LPA met with Staff #1 (S1) Grace Park and explained the reason for today’s inspection. Administrator (AD) Erik Doan was not present during the inspection. The Long-Term Care Ombudsman (LTCO) for the facility was present during the inspection to translate. During the inspection, LPA, LTCO, and S1 toured the facility. LPA and LTCO interviewed residents. LPA requested and reviewed copies of the resident roster and staff roster. Based on today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 7, 2023

Allegation investigated: Facility did not respond to resident's call for help in a timely manner.

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 LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 During today's visit, LPA requested to obtain the facility's current census. A tour of the physical plant and unit assigned to resident R1 was additionally conducted. Regarding the allegation that Facility did not respond to resident's call for help in a timely manner, the following has been concluded: In the early hours of January 18, 2023, resident R1 suffered a fall incident in his bedroom at the facility. The fall occurred in the interval between two rounds being conducted, between the hours of 1:40am and 5:00am as certified in the log maintained by staff to document resident checks by the overnight staff. The exact time of occurrence could not be assessed from the evidence gathered. Resident R1 was found by staff member S1 and assisted back into bed. Later that day, resident kept displaying signs of pain, which led to 911 being called. Resident R1 was assessed at the facility and transported to the Emergency Department at UCI Hospital before being released to a Skilled Nursing Facility with a diagnosis of a compression fracture of the seventh thoracic vertebra. At the time of the present visit, the resident is stated to have been admitted back into the facility and appears to be doing well. The evidence gathered did not allow to make a precise determination of the time interval between the fall and assistance being provided to the resident. As a result, the allegation is deemed to be Unsubstantiated,meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided and left to facility representative.the state’s words, verbatim · CDSS document, Apr 12, 2023 · control 22-AS-20230119153437

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting deficiencies observed during the investigation of the allegation included in complaint 22-AS-20230119153437. It was determined over the course of the investigation that half rails were in place on resident R1's bed when resident sustained a fall incident early in the morning of January 18, 2023. Based on interview with the facility's administrator and records reviewed during an initial investigation visit conducted in January, there were no physician orders in place to authorize the use of postural supports at the time. LPA observed the unit during today's visit. The half rail was noted to be present and mounted to the bed in the lowered position. LPA requested to review the resident's file for the presence of a doctor's order which was provided. Additionally, it was determined that no incident report for the fall and subsequent hospitalization on January 18, 2023 were submitted by then administrator Hyo Sook Kim before the complaint investigation visit conducted on January 28, 2023. LPA provided a consultation with the current facility regarding the implications of making potentially false statements to a licensing agent. Two Type B deficiencies are cited according to Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeals rights was provided and left to facility representative.the state’s words, verbatim · CDSS document, Apr 12, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Apr 26, 2023

The California Code of Regulations Section 87608(a)(3) states that: "A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record." This requirement is not met as evidenced by: Based on records reviewed, observation conducted and interviews, it was determined that half bed rails were in place without a physician report at the time of the fall incident on 01/18/2023. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: Licensee will obtain physician order for postural support for resident R1 and submit it to LPA before the Plan of Corrections due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(B) · Plan of correction due date: Apr 12, 2023

The California Code of Regulations Section 87211(a)(1)(B) on Reporting Requirements states that: "A written report shall be submitted (...) within seven days (...) [for] Any serious injury (...) occurring while the resident is under facility supervision." This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, it was determined that licensee failed to submit an incident report prior to the facility inspection on 01/28/2023. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: Licensee provided a late report during the facility visit in January, the deficiency is therefore cleared.

Allegation investigated: Facility did not release resident records to the legal representative.

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 03/27/2023. Substantiated Based on a preponderance of evidence through interviews the allegation facility did not release resident records to the legal representative is SUBSTANTIATED, meaning the complaint allegation was valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to facility staff.the state’s words, verbatim · CDSS document, Mar 27, 2023 · control 22-AS-20230323114408

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Mar 31, 2023

(c) All information and records obtained from or regarding residents shall be confidential.(1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This was not met as evidenced by the facility not providing documents after a formal request was made. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2023

Plan of correction: Administrator to provide requested documents by POC due date and forward proof to LPA.

Type of visit: Case Management - Other

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting additional interviews for Complaint Control No. 22-AS-20220907180032. LPA met with Administrator (AD) Hyo Sook Kim and explained the reason for today’s inspection. During the inspection, LPA interviewed AD and requested and reviewed copies of the resident roster and staff roster. AD identified 8 residents who regularly attend the church service activity in the common room. LPA interviewed 2 of these residents. Facility representative was advised that at this time further investigation may be required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Oct 26, 2022

Allegation investigated: Staff restrained resident

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad to investigate the above-mentioned complaint allegation. LPA met with Administrator (AD) Hyo Sook Kim and explained the reason for today’s inspection. The investigation into the allegation that Staff restrained resident revealed the following: During the course of the investigation, LPA conducted a health and safety check on Resident #1 (R1), interviewed AD, staff, and witnesses, and requested and reviewed copies of the resident roster, staff roster, and training records. A witness stated in interviews that on 08/24/22 they observed R1 in the activity room tied to their wheelchair with a scarf, they were told by R1 that staff had tied R1 to the wheelchair because they keep trying to get up from the wheelchair, and they called AD over who immediately removed the scarf from R1. When interviewed, AD admitted that this incident occurred as reported, but stated they were not aware that R1 had been tied to their wheelchair. Substantiated AD identified Staff #1 (S1) as the staff who had tied R1. In interviews, S1 stated that earlier that morning R1 had fallen from their wheelchair, that R1 kept trying to stand but was not able to stand or walk, so S1 used a scarf to secure R1 to their wheelchair for R1’s safety because the wheelchair did not have a seatbelt and R1 did not know that it was improper to tie residents to wheelchairs. S1 stated that they now know not to do it again. AD stated that shortly after the incident they trained staff to never to tie residents to their wheelchairs and to report any such incidents. On 09/14/22, LPA conducted a health and safety check on R1 and observed R1 to be in good health and good spirits. 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. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. AD stated that the staff conducting the activity arrived within minutes of AD arriving to the activity room. While the residents may have been left alone in the activity room, they were only left alone for a few minutes and staff were going back and forth to the activity room bringing residents to the activity and the staff conducting the activity arrived shortly thereafter. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Sep 14, 2022 · control 22-AS-20220907180032

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Sep 15, 2022

87468.2 Additional Personal Rights … (a) In addition to the … (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure R1 was free from neglect, punishment, and physical abuse when a staff member tied R1 to their wheelchair, which poses an immediate personal rights and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2022

Plan of correction: Licensee stated they already trained all caregivers never to tie residents to wheelchairs and to report any such incidents. Licensee provided proof to LPA during the inspection. Licensee stated they will train all other employees never to tie residents to wheelchairs and to report any such incidents and to provide proof of training to LPA within 5 days of POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced Case Management visit in conjunction with complaints visit 22-AS-20200325124107 and 22-AS-20200917155010. LPA Martinez met with Licensee Erik Doan and explained the reason for the visit. Administrator Hyo (Monica) Sook Kim arrived shortly after. During the course of the complaint visit, LPA Martinez and Licensee Doan toured the inside and outside of he facility. LPA Martinez noted a wheelchair laying on its side blocking the exit gate door on the outside of first floor by Memory Care. Gate door was also tied with a cloth at the top (pictures taken). Licensee Doan did not have an explanation for it other than they had a resident from Memory Care AWOL some days ago. Based on the observations made during today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with AD Monica Kim and a copy of the report will be emailed along with Appeal Rights.the state’s words, verbatim · CDSS document, May 17, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 18, 2022

Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met as evidenced by: LPA and Licensee observed a wheelchair laying on its side blocking an exit gate door on the outside of the first floor by Memory Care. Gate door was also tied with a cloth at the top. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2022

Plan of correction: Administrator states the staff will be trained in Fire Safety, Evacuation and Resident Rights. Administrator agrees to ensure the facility exits will not be blocked for any reason. Administrator to forward proof of correction by POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Licensee (LE) Erik Doan, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 05/01/2021. This is a change of ownership. This is the second pre-licensing inspection. Please see LIC809 dated 02/18/2022. During today’s inspection, LPA observed the following items have been corrected: (1) kitchen refrigerator temperature tested at 38 F degrees and freezer tested at 0 F degrees; (2) there are now evacuation chairs at the top of all 5 stairways. LPA explained the process of this application and about the post licensing inspection once the facility is licensed. LE was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. Component III was completed with LE during the initial pre-licensing inspection. An exit interview was conducted and a copy of this report was discussed with and provided to LE.the state’s words, verbatim · CDSS document, Feb 22, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Licensee (LE) Erik Doan, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 05/01/2021. This is a change of ownership. During the inspection, LPA and LE observed the following. Structure. This is a large commercial facility. Facility is a 170-bedroom, 180-bathroom, 3 story building. There is 1 large patio with patio covers for the clients. Facility telephone number is (562) 694-6515. Bedrooms Residents. The client bedrooms are spacious and will easily accommodate the client's furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Bedrooms staff. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 and 120 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed, including the wired smoke detector/carbon monoxide detector. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen. Toxins: observed in the locked storage rooms. Medication room and cabinets are locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection, LPA reviewed resident and staff file storage area. Fire clearance was approved by LA County Fire Department Inspector Eddie Martinez on 02/16/2022. Patio. Patio exit door is operational and unlocked. Patio has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with LE during today’s inspection. Facility is currently operating under the liability insurance of current facility BOK SENIOR HOTEL (306005182). LE will switch liability insurance to new facility once the application is approved. During the inspection, LPA and LE observed the following: (1) kitchen refrigerator temperature tested at 45 F degrees and freezer tested at 5 F degrees; (2) all stairways lacked evacuation chairs. LE agrees to correct these items and submit proof of completion to LPA Haddad on or before 02/22/2022. During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. LE was informed the items listed above must be completed for the facility to meet Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to LE.the state’s words, verbatim · CDSS document, Feb 18, 2022