Graces Home

Licensing Program Analyst (LPA) Samer Haddadin made an unannounced required annual inspection at this facility. LPA met with Administrator Mai Ngoc and stated the purpose of this visit. The facility is a single level home and licensed for six non-ambulatory of which two may be bedridden with a hospice waiver for six. This facility is a Residential Care Facility for the Elderly/Dementia. The facility had 6 bedrooms in which 4 are used for resident and 2 for staff members. LPA toured the interior and exterior portions of the facility. Resident rooms were provided with furniture, chair, clean linen, adequate storage space, and kept free of tripping hazards. Hard wired smoke detectors, carbon monoxide and audible exit alarms were tested to be operational. LPA did not observe the required PUB 475 to be in the right size. Also, LPA asked AD for liability insurance, AD stated he does not have one currently on his person will provide it. LPA did not observe any emergency drill documentation. All files of staff and clients contained all required documentation. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 126.6 degrees Fahrenheit. Facility did not met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. For the exterior portion, facility did not have a shaded area and nor chairs; grounds were unclear of tripping hazards and no space for activities. Facility has a 2-car garage and is kept locked and used for storage; the garage also had an operational washer and dryer. Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. . ***THIS IS AN AMENDED REPORT***

Per interview with AD Mai allows R1 to sit outside on the facility front porch unsupervised. AD stated he leaves the front door unlock for R1. AD explained that R1 usually comes back from outside and goes in their room and closes their door. The night of the incident, AD Mai check and saw a blanket covering R1’s pillow and thought R1 was in bed. AD stated he didn’t hear R1 leave. AD reported the door alarm was turned off because it irritates R1. AD Mai was not aware that R1 was missing until in the morning where he usually wakes up R1 for breakfast. Upon realizing R1 was missing, AD checked the facility and surrounding neighborhood and notified police & R1’s responsible party. AD does not recall notifying CCLD about R1's elopement. LPA did not find any SIRs from the facility around that time period of the incident. R1 was brought to UCI Medical Center via paramedics after a syncope and collapse. After a series of tests, R1 was diagnosed with facial trauma to their forehead and nose. Per hospital discharge paperwork dated 2/2/23, R1’s head CT scan did not show any signs of acute intercranial hemorrhage, herniation or hydrocephalus. AD Mai was not aware that R1 was brought to the hospital upon admission. AD Mai was contacted by hospital staff upon finding his business card in R1’s pocket. Hospital records note R1 did not recall the event and was unclear how they came to be in Orange County. LPA attempted to interview R1 who refused to speak with LPA. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation facility staff did not adequately supervise resident while in care is determined to be SUBSTANTIATED, meaning the complaint allegation is 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 with Caregiver Quy "Anna" Mai and Ngoc “Nick” Mai over the phone and a copy of this report and appeal rights was provided.

On today's date, Licensing Program Analyst (LPA) Michael Tea conducted this case management in conjunction with the continued Complaint visit Control #:22-AS-20230203140953. LPA Tea met with Caregiver (CG) Quy "Anna" Mai and discussed purpose of today's case management visit - Deficiencies visit. Administrator Ngoc "Nick" Mai was not present but LPA spoke to AD Mai over the phone. During the visit LPA Tea was greeted and granted entry by a new staff, Sau Nguyen. LPA observed that AD was not present and just the staff was alone with the residents at the facility. LPA was able to talk to AD Mai over the phone and asked where he was. AD Mai said he is far away from the facility in San Bernardino obtaining cooking utensils for the facility and that the residents are being supervised by the present staff who is AD Mai's cousin, who he plans to hire as a caregiver for the facility. AD Mai said that he was testing him out with the residents. LPA Tea asked AD Mai if he had the staff fingerprinted and passed background clearance. AD Mai said he just started the paperwork. LPA explained that all staff whether test trial or not is required to have full background clearance to be at the facility. AD Mai understood and said that he will have his sister, Quy "Anna" Mai an on-call caregiver come to facility within in half an hour. LPA observed there is not enough staff to care for residents, especially when AD Mai is away. Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for the deficiencies. An exit interview was conducted with Caregiver staff Quy "Anna" Mai and Administrator Nick Mai over the phone a copy of this report LIC809 and LIC809D and appeal rights were provided at exit.

Based on interview with Licensee Mai he stated that a partial payment was made on 03/01/2024 and the remaining balance was paid on 03/08/2024. LPA Mendivil received a copy of receipt of both payments from 03/01/2024 and 03/08/2024 while at the facility. It was confirmed by Anaheim Public Utilities if the balance was paid then there would not be a disruption in service. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation facility failed to pay electricity bill timely is determined to be SUBSTANTIATED, meaning the complaint allegation is 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 the facility representative.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purposes of conducting a case management deficiency in connection to the investigation completed under complaint control number: 22-AS-20221110131242. LPA Quiroz was greeted and granted entry into the facility by Administrator Ngoc "Nick" Mai 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. The investigation found the following: Hospital records confirm that R1’s responsible party informed hospital staff that R1 was not brought in by their caregiver due to caregiver having two other people to take care of. Facility was cited for lack of staffing on 2/07/2023 during a Case Management inspection by the Department. As of today’s date, the Plan of Correction has not been met. When interviewed regarding the fall, the Administrator reported they did not submit a written unusual incident report (UIR) to the Licensing Department as they didn’t think it was necessary as they believed R1 to be improving. The Administrator further reported they did not contact 9-1-1 as they believed the family would handle R1’s medical needs and that by contacting R1’s family, the Administrator believed he had met his Administrator duties. Following R1’s fall it was reported R1 was no longer able to walk. Hospital records from 11/09/2022 confirm R1 sustained a closed hip fracture. Despite the change in condition, no updated reappraisal was observed on file. In addition to the above noted incident, hospital records note R1 was hospitalized on 8/26/22 due to being hypotensive. While there, blood glucose levels for R1 were noted to be 244. The following is being cited per California Code of Regulations, Title 22 Division 6 Chapter 8. (SEE LIC 809-D Pages) An exit interview was conducted with Administrator and a copy of this report, confidential names list and appeal rights was provided at the time of exit.

Although R1 did sustain an unwitnessed fall, it remains unclear if the fall was caused due to a lack of supervision on behalf of facility staff. Based on the investigation, the allegation that Facility did not provide adequate supervision resulting in resident jumping out a window was found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report, and confidential names list was left at the facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 CONTINUED...When Interviewed by the Department and asked why they did not have R1 transported to the hospital, R1’s responsible party stated they believed R1 to be improving and didn’t think the situation was serious despite R1’s continued inability to walk. R1’s primary care physician was not contacted nor notified of the fall at the time of incident. During a visit to the facility on 11/09/2022, R1’s responsible party requested R1 be taken to the hospital for evaluation on their hip. R1 was taken to the hospital approximately a month after the initial fall where they were diagnosed with a displaced left hip fracture. The Administrator reported they expected that the family would handle R1’s medical needs. R1’s responsible party told hospital staff they were unable to take R1 to the hospital sooner due to being busy. Hospital records reviewed note that R1’s responsible party reported R1 was not brought in by their caregiver as the caregiver had two other people to take care of. R1’s responsible party reported to hospital staff R1 has memory difficulties and is often confused. R1’s family declined surgical intervention due to R1’s age. R1 eloped from the hospital prior to being discharged with the assistance of their responsible party and returned to the facility against medical advice. R1’s physician report dated 7/12/2022 lists R1 as ambulatory prior to the fall. Following the fall, R1 was unable to walk and relied on a wheelchair for transportation. An interview with R1’s responsible party confirms that R1 is no longer able to ambulate following the fall. Based on the investigation, the allegation that Facility staff did not seek medical attention for resident in a timely manner was found to be SUBSTANTIATED. The following is being cited per California Code of Regulations, Title 22 Division 6 Chapter 8. A civil penalty is pending determination, per H&S Code Section 1569.49(f). An exit interview was conducted with Administrator and a copy of this report, confidential names list, civil penalty, and appeal rights was provided at the time of exit.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted this case management- Deficiencies visit in conjunction to the 10 day visit for Complaint Control#22-AS-20230203140953. LPA Quiroz met with Licensee/Administrator (L/AD) Ngoc "Nick" Mai and discussed purpose of today's case management visit- Deficiencies visit. During 10 day visit for complaint control#22-AS-20230203140953, LPA Quiroz along with (L/AD)Ngoc "Nick" Mai took a tour of the physical plant of the facility interior and exterior of facility premises. Between 9:53am-12:50pm, LPA Quiroz inspected resident’s bedrooms, kitchen area, garage area, back yard area and all common areas in the facility. During today's facility tour inspection between 9:53 am-12:50pm, LPA Quiroz observed uncleaned stove with grease stains, food with no label dates, food and trash particles throughout the kitchen area, living room area, common living areas, pair of scissors, diabetic used lancet in kitchen dining-room. LPA Quiroz observed gardening tools varying in sizes from small to large, 2 paint containers, automobile door white in color in backyard area readily available to residents in care. LPA Quiroz observed outdoor and indoor passageways obstructed throughout the garage and in staff office area. This was verified with (L/AD) Mai indicating understanding the risk to residents in care. During today's visit, LPA Quiroz conducted interviews with interviewees and reviewed 4 of 4 resident's records. During today's record review, LPA Quiroz did not observe physician reports on file for Resident 1 (R1) and Resident 2 (R2). During today's record review but not limited to Discharge paperwork from UCI Medical Center for R1, LPA Quiroz observed resident was tested positive for COVID-19 during admission and discharge. FAS records indicate no COVID-19 positive reporting to Community Care Licensing (CCL). This was verified with (L/AD) Mai indicating " I thought the pandemic was over. I forgot." Based on this inspection, multiple deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations . (See LIC 809-D pages for deficiencies). Civil Penalties were also assessed during today's visit. This report was reviewed with (L/AD) Mai and a copy of this report LIC 809, LIC 809-D pages, LIC 811- Confidential Names, LIC 421 IM- CIVIL PENALTY ASSESSMENTS – IMMEDIATE $500 AND REPEAT VIOLATIONS and Appeal Rights were provided to (L/AD) Mai at exit.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted this case management in conjunction to the 10 day visit for Complaint Control #:22-AS-20221110131242. LPA Quiroz met with Licensee/Administrator (L/AD) Ngoc "Nick" Mai and discussed purpose of today's case management visit- Deficiencies visit. During the visit LPA Quiroz along with Licensee Administrator Ngoc "Nick" Mai took a tour of the physical plant of the facility indoor and exterior of facility premises. Between 10:13am-10:42am, LPA Quiroz inspected resident’s bedrooms, kitchen area, garage area, back yard area and all common areas in the facility. During today's facility tour inspection between 10:13 am-10:42am, LPA Quiroz observed medications with label and no label in kitchen area and in Resident 4 (R4) bedroom area, uncleaned stove with grease stains, food with no label dates, spider webs, food and trash particles throughout the kitchen area, living room area, common living areas, soiled clothes in Resident's 3 bathroom area, bottles of wine in refrigerator, scissors, four knives on kitchen counter/sink area readily available to residents in care. This was verified with (L/AD) Mgoc Mai. (L/AD) Mai indicated "I understand the risk." Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations . See LIC 809-D for deficiencies. A Civil Penalty was also assessed during today's visit. This report was reviewed with (L/AD) Ngoc Mai and a copy of this report LIC 809, LIC 809-D pages, LIC 811- Confidential Names, LIC 421 IM- CIVIL PENALTY ASSESSMENT – IMMEDIATE $500 AND REPEAT VIOLATIONS and Appeal Rights were provided to (L/AD) Ngoc Mai at exit.

Licensing Program Analysts Michelle Reed and Edward Tapia conducted a visit to discuss Complaint # 22-AS-20220421083332. During the visit, LPAs noted the following Staff #1 was not fingerprint cleared or associated to the facility and has been working for at least a month. The common bathroom is also under construction and all residents are being showered in the master bedroom that is being occupied by Resident #3. See LIC 809D for cited deficiencies. An exit interview was conducted and a copy of this report and appeal rights were given to Ngoc Mai.