Grace Retirement Village.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad and Regional Manager (RM) Monica Tran for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20260622113001. LPA and RM met with Staff #1 (S1) Judith Lee and explained the reason for today’s inspection. During the course of the investigation, LPA and RM inspected the facility and observed the following: the hard wood flooring in certain areas of the first floor memory care hallway is cut, peeling, lifting, and shredding, which poses a potential fall risk to residents and visitors, and the third floor common area flooring around room 325 is cut, peeling, lifting, and shredding, which poses a potential tripping hazard to residents and visitors. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. 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.

It was alleged that R1 received IV infusions with an IV bag that had a partially peeling or missing label, R2 received IV infusions with an IV bag that had another resident’s name on it, and the facility had no doctor’s orders for the IV infusions. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who admitted the allegation, stating that on March 16, 2026, R1 and R2 were administered IV infusions due to weakness and not eating, the IV infusions were ordered by the residents’ nurse practitioner verbally but a written order was not received until the nurse practitioner arrived at the facility on March 18, 2026, and that the IV bags given to these residents were from the facility’s stock and were not delivered to the facility for these residents. LPA reviewed R1’s IV Order dated March 13, 2026, and R2’s IV Order dated March 16, 2026, which per AD were written on March 18, 2026, but given verbally on March 16, 2026, and noted they are for “IV 05 ½ NS”. LPA observed six IV bags at the facility, none of which were labeled for R1 or R2. Two bags were labeled for Resident #3 (R3), who per AD is no longer a resident of the facility and moved out on October 31, 2025. All six IV bags are labeled as “Sodium Chloride 0.9% Solution”. However, the labels of the bags actually administered to R1 and R2 are no longer available. AD stated they are not knowledgeable about IV bags, but the nurse who administered them would have handled it. LPA attempted to interview the nurse that administered the IVs to R1 and R2, but was unsuccessful. LPA interviewed two staff who were unable to provide information regarding this allegation. LPA reviewed the Medication Administration Records for R1 and R2, which did not contain orders for IV infusions or document the IV infusions administered. Although the facility eventually received written doctor’s orders documenting that IV infusions were ordered for R1 and R2, R1 and R2 received IV bags that were delivered to the facility other residents and it is unknown if they received the correct IV bags as ordered by their doctor. 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. 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 It was alleged that Resident #1 (R1) and Resident #2 (R2) received IV infusions at the facility without staff or licensed supervision present. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who denied the allegation, stating that the IV infusions were administered by the facility’s on-call registered nurse. LPA interviewed two staff who were unable to provide additional information. When interviewed, R2 was unable to provide information regarding the allegation, but R1 stated a nurse administered their IV and staff stayed with them while it was in place. LPA attempted to interview the nurse who administered the IV, but was unsuccessful. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above 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.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with staff James Lee and Administrator (AD) Michelle Song and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 7:45AM, LPA and staff James Lee conducted a preliminary inspection of the facility. At about 1:30PM, LPA, AD, and staff James Lee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and 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 residents. Resident Bedrooms: the 19 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 19 resident bedrooms inspected. LPA tested the call button in multiple resident rooms in assisted living and memory care and noted prompt staff responses. LPA tested the delayed egress system in the first floor memory care and observed it to be functioning properly. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees and 122 degrees F, before corrections, in the 12 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid but are not yet due. At about 9:00AM, LPA reviewed 10 resident files and 10 staff files, interviewed 6 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. 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 During the inspection, LPA and AD observed the following: based on observation, out of the 12 bathroom faucets tested, all were within range except Room 123 which tested at 122 degrees F; based on documents, S3's health screening is dated more than 6 months before their association date, S4 did not have a health screening in their file, and S9's health screening states they are positive for tuberculosis which S9 states is a mistake and S9's doctor stated over the phone they believe is a false positive and they will order a chest x-ray to confirm; based on documents, S5, S6, and S9 did not have records of their 40 hour initial training; based on documents, S2, S3, S4, S7, and S8, did not have records of their 20 hour continuing training; based on documents, S4 and S5 did not have current first aid certificates in their files; based on documents, the facility has a memory care unit but their training records indicate that no staff has received 12 hours of dementia initial training or 8 hours of dementia continuing training; based on documents, medication technician S8's medication training records do not document the number of hours or type of training and medication technician S9 had no medication training at the facility; based on documents, the physician's reports for R1 through R10 are on the old form and do not include required information, such as descriptions of behavioral expressions; based on documents, the appraisals for R2, R6, R7, R8, R9, and R10 are more than a year old; and based on documents, the admission agreement in R2's file was blank. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on November 19, 2025 regarding Resident #1 (R1). LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD, and requested and reviewed copies of the resident roster, staff roster, and resident files. Per the incident report received in the OCRO on November 19, 2025, on November 2, 2025, R1 left the facility without staff noticing around 6AM, was found by the police miles away, and was sent to the hospital. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA reviewed R1’s Physician’s Report dated February 6, 2025, which indicates R1 has mild cognitive impairment but can leave the facility unassisted. Per AD, R1 did not have dementia, but lived in the memory care unit due to psychiatric issues. Per AD, R1 is still at the hospital, R1 escaped by using a chair to jump a fence in the memory care courtyard and did not trigger the facility’s delayed egress alarms, and R1 was hospitalized after fighting with police when they were found on November 2, 2025 but AD is unaware of any injuries to R1. LPA reviewed R1’s involuntary evaluation application dated October 30, 2025, which indicates that prior to R1’s elopement on November 2, 2025, R1 was detained by Garden Grove Police Department during another elopement on October 30, 2025, due to being gravely disabled, being observed walking in street traffic due to their dementia. Per facility staff, R1 leaving on October 30, 2025, was also not noticed by staff and no delayed egress alarms were triggered and it is believed R1 jumped another fence. Per facility staff, on October 30, 2025, R1 was hospitalized but was cleared to go back to the facility the same day or the next day by the doctor at the hospital, facility staff protested R1’s return to the facility to the doctor at the hospital, but R1 was still returned to the facility and the doctor said they would send new medications to R1’s pharmacy. 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 Per AD and facility staff, the facility did not have a chance to reassess R1 as they eloped again in the next few days on November 2, 2025, and it is unclear if the new medications ever arrived. Facility staff stated they put R1 on 30-minute checks after their first elopement, but there are no logs available, and the checks provided by facility staff were insufficient to meet R1’s care and supervision needs. Based on the information obtained, the facility did not put in place sufficient measures to address R1’s elopement even after knowing of their previous elopement a few days earlier. LPA inspected the delayed egress doors in the memory care unit and confirmed they work properly. LPA reviewed the incident reports received in the OCRO and noted that R1’s elopement on October 30, 2025 was not reported. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

Regarding the allegation that facility staff did not properly document resident medications: it was alleged that the facility did not document R1’s Morphine and Lorazepam, Resident #2’s (R2) Morphine and Lorazepam, and Resident #3’s (R3) Morphine. LPA inspected the facility, conducted health and safety checks on R1, R2, and R3, and observed no health and safety issues. LPA interviewed AD, who admitted the allegation, stating that these residents were on hospice and had these medications delivered to the facility upon being admitted to hospice but the centrally stored medication records and medication administration records for these residents did not include these medications despite AD’s multiple attempts to get the hospice company and pharmacy to include these medications on these documents. LPA reviewed the centrally stored medication records and medication administration records for R1, R2, and R3 and confirmed that these medications were not included on these documents when the medications were delivered to the facility and in the case of R1 and R2 were not included on these documents for multiple months. Regarding the allegation that facility staff did not dispose of expired medications: it was alleged that on October 30, 2025, bottles of expired antacids and anti-gas medications were found in the medication room with expiration dates of August 2025, multiple expired suppositories were found in the medication room refrigerator with expiration dates of July 2025, and AD and the medication technician were notified and stated they would destroy these expired medications and reorder new ones. LPA interviewed AD who admitted the allegation, stating that expired medications were found in the facility’s medication room and that after being made aware of the expired medications, facility staff destroyed them following the facility’s protocol. AD stated they did not believe these medications were given to residents after they expired. Regarding the allegation that facility staff did not ensure resident wound care was properly documented: it was alleged that R1 did not have documentation of the wound care for R1’s stage 1 pressure wound. LPA reviewed R1’s hospice medical records which indicate that on October 24, 2025, R1’s doctor diagnosed R1 with a stage 1 pressure ulcer and gave an order for wound care. LPA interviewed AD who admitted the allegation, stating that the facility was unaware that R1 had a wound or was receiving wound care and the facility did not have documentation for the wound care provided by R1’s hospice company as of October 30, 2025, but that the facility requested and received the wound care records at a later date. AD stated that apart from the wound care R1 received from their hospice care team, R1 received the facility’s standard repositioning care from the facility’s own staff, but that this care was not documented either. 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 LPA reviewed R1’s hospice medical records which shows that R1 received wound care from their hospice care team, but this documentation was not obtained by the facility until weeks after the wound care began and is still incomplete for the time period between October 24, 2025 and November 10, 2025. 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. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

It was alleged that the facility has visible mold in the kitchen where staff prepare food. LPA reviewed photographs showing black mold on the ventilation pipes in the kitchen with condensation dripping down onto food prep areas. LPA inspected the kitchen and observed that the exterior of the ventilation pipes had been partially cleaned, but that some of the mold was still present on the pipes, and also observed staff conducting a deep cleaning of the kitchen. LPA observed additional black mold behind a short chest freezer in the kitchen that had not been cleaned and as well as additional mold near the vents in the first floor memory care common area and second floor chapel room. LPA interviewed AD who stated the facility is currently deep cleaning the kitchen, has taken alternative measures to ensure residents are receiving safe and healthy food, and that the facility has already called a professional to clean the mold and ensure the facility is mold free. While the facility is now taking steps to address the mold, the information obtained corroborated that the facility did not timely address the mold as it grew throughout the facility, including the kitchen. 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.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701 and while reviewing the facility’s insurance policy. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility and observed the following: while the facility was licensed with a single memory care on the first floor, LPA observed that an additional memory care has been set up on the third floor with functional delayed egress doors. Per interviews with AD and Licensee (LE) Erik Doan, the facility began keeping residents with memory issues in this third floor memory care early in 2025 in order to provide closer supervision and to separate them from the ambulatory memory care residents in the first floor memory care. AD and LE provided conflicting information regarding whether these residents needed to be in a memory care. However, the facility did not notify LPA of this new memory care with delayed egress, request an update to its plan of operation, or receive approval for this change and LPA first learned of this new memory care after observing it months after it was created. During the inspection, the maintenance manager attempted the deactivate the delayed egress doors but was unsuccessful. LE stated they will deactivate and permanently disassemble the delayed egress system on the third floor and will ensure all residents who need to be in a memory care are relocated to the first floor memory care. LPA advised LE on the process for properly requesting a new memory care for approval if LE is interested in adding a third floor memory care. CONTINUED 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 On April 23, 2025, Department staff requested a copy of the facility’s insurance policy. On April 23, 2025, LE submitted to LPA the facility’s insurance certificate and binder for the period November 12, 2024 to November 12, 2025 for the insurance policy ending in 8506. However, review of this insurance binder revealed that the facility’s insurance does not provide the required coverage of “injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees,” including because the insurance contains sub-limits of one hundred thousand dollars ($100,000) per occurrence and three hundred thousand dollars ($300,000) in the total annual aggregate for claims relating to elopement, sexual abuse, and pressure injury, which are typical injuries and issues seen in this facility type. Based on the information obtained, the facility currently does not have insurance that is compliant with Title 22 Regulations. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, Department staff inspected the facility, interviewed staff, and obtained and reviewed copies of the resident roster, staff roster, an Incident Report dated July 15, 2024, and Resident #1’s (R1) UCI Medical Records. Per an Incident Report dated July 15, 2024, on July 15, 2024, at 9:00AM, R1 was found with a right swollen leg and sent to the hospital. R1’s UCI Medical Records and staff interviews revealed that R1 was diagnosed at the hospital with a femur fracture as a result of this incident. However, based on Orange County Regional Office (OCRO) records, the facility did not submit the Incident Report dated July 15, 2024, to the OCRO or submit any other incident reports regarding this injury as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

It was alleged that, due to lack of care and supervision by facility staff, R1, who is bedridden and wheelchair bound, sustained an unstageable wound on their tailbone at the facility. Per R1’s UCI Medical Records, on July 15, 2024, R1 was admitted to the hospital and diagnosed with a 2.5 centimeter by 2.5 centimeter unstageable bed sore on the tailbone which is black in appearance. Per R1’s Physician’s Report dated March 23, 2024, R1 has Dementia, is non-ambulatory and uses a wheelchair, and is incontinent. R1’s undated Appraisal/Needs and Services Plan indicates R1 is incontinent, uses diapers, and requires staff to change their diapers. Four staff described that R1 needs assistance with all activities of daily living and spends a majority of their time in bed. Based on this information, R1 was at risk for developing pressure injuries. Three staff stated that residents are repositioned and checked for skin conditions every two hours, as well as during clothing changes, diaper changes, and showers, but no body check logs are maintained and instead any issues are reported verbally to the medication technician. Staff #1 (S1), who changed R1 at least once during the overnight shift from 10:30PM on July 14, 2024, to 7:00AM on July 15, 2024, denied seeing any wounds on R1, but also denied that they were properly repositioning R1 because R1’s body is very rigid. Staff #2 (S2) stated they noticed a quarter-sized red wound on R1’s tailbone around July 8, 2024, they reported it to Staff #4 (S4), the facility’s medication technician, and they put cream on the wound but were unable to tell if the wound was improving. S4 claimed they first learned of R1’s wound on July 15, 2024, confirmed they are not qualified to provide wound care, and stated that when they learned of R1’s wound on July 15, 2024, they reported to Witness #1 (W1), a third-party nurse who was present at the time. W1 stated they have previously provided treatment for R1’s occasional rashes, on July 15, 2024, they were advised by S4 of R1’s wound, they were unable to assess the wound due to R1 having a separate injury which required transfer to the hospital, but they were able to place a bandage on the wound prior to R1 going to the hospital. R1’s Nurse Progress Notes, which date from May 18, 2024, through R1’s hospitalization on July 15, 2024, do not document that any wounds were noticed or treated. Based on the information obtained, facility staff were not properly repositioning R1 and did not obtain assessment or treatment for R1’s wound for a week after its discovery around July 8, 2024. 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. 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. 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 It was alleged that, due to lack of care and supervision by facility staff, R1, who is bedridden and wheelchair bound, sustained a right femur fracture which required hospitalization. Per R1’s Physician’s Report dated March 23, 2024, R1 has Dementia, is non-ambulatory and uses a wheelchair, and leans forward while in a wheelchair which indicates that R1 is a fall risk. Four staff described that R1 needs assistance with all activities of daily living, spends a majority of their time in bed, cannot get out of bed or their wheelchair alone and does not attempt to do so, and requires two staff to transfer between their bed and wheelchair. Per Staff #1 (S1), on July 15, 2024, between 5:30AM and 6:00AM, they checked on R1, observed R1 moving around in bed, was starting to change R1 but heard a noise like a bone moving, did not observe any visible injuries, and reported the issue to Staff #2 (S2) and Staff #3 (S3) at shift change. S1 worked the overnight shift from 10:30PM on July 14, 2024, to 7:00AM on July 15, 2024, and had changed R1 previously during this same shift and did not notice any issues with R1. Per S2 and S3, on July 15, 2024, around 5:30AM, they went to R1’s room, saw R1 in bed, were advised by S1 that R1 was not acting normal, but noted that R1 was comfortable, eating breakfast, and not complaining of pain. S2 also provided a conflicting statement that they saw R1 on the floor and placed R1 back in bed, but later rescinded this statement. S2 and S3 had also worked on July 14, 2024, changed and bathed R1, and did not notice any issues with R1 on that day. Two additional staff provided statements that they observed no issues with R1 on July 14, 2024, and staff interviews and facility records did not reveal any reported falls for R1 relating to this injury. Staff #4 (S4), the facility’s medication technician, stated they were advised of the situation with R1 on the morning of July 15, 2024, they checked on R1 and noted R1’s upper right thigh was swollen, and they called an ambulance and requested an assessment from Witness #1 (W1), a third-party nurse who was present at the time. Per W1, after being advised of the issue with R1, they assessed R1, observed swelling on R1’s thigh but no redness or bruising, and noted R1 did not complain about pain. R1’s UCI Medical Records reveal that on July 15, 2024, R1 was diagnosed with a “displaced comminuted fracture of shaft of right femur”, which is a fracture in the large upper leg bone where the bone is in at least three pieces which are no longer in alignment, R1 underwent “R femur ORIF” on July 16, 2024, which is a surgery to realign and connect the broken pieces of bone using a plate and screws, and R1 was recommended for hospice. One of R1’s treating physicians provided a statement indicating they could not definitively say what caused R1’s fracture, it is highly likely it was caused by a rotational injury, but due to R1’s age and poor quality of bone structure, it is possible the fracture may have been caused when R1 moved or their leg was moved by another person to change them. The information obtained regarding what caused R1’s fracture is conflicting and did not corroborate the allegation. 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 Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above 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.

Regarding the allegation that facility staff did not obtain timely medical care for resident: it was alleged that the facility did not obtain timely medical care for R1 after their fall. R1’s responsible party stated that, prior to April 2024, R1 was able to talk, walk, and eat, and that R1 had been seen by their doctor and determined to be in good health. Per R1’s Physician’s Report dated February 28, 2024, R1 had confusion but was able to follow instructions and communicate their needs. Per R1’s Primary Care Medical Records, R1 was referred to home health for physical therapy relating to movement on February 29, 2024, R1 had diagnoses of Dementia, major depressive disorder, abnormalities of gait and mobility, and generalized muscle weakness, and R1 required a walker. Per R1’s Primary Care Medical Records, R1’s doctor examined R1 on March 22, 2024, and noted R1 to be alert to person, place, and time and determined R1’s physical examination to be within normal limits. R1’s Home Health Medical Records revealed that R1 required assistance with most activities of daily living, could not independently make changes in body position, required a walker for walking, and had multiple risk factors for falling, including a prior history of falls within three months. R1’s Home Health Medical Records indicate that physical therapy sessions were conducted at the facility, R1 had good participation in all exercises, was making progress, had a good appetite during the March 28, 2024, and April 4, 2024, sessions, but was noted as having new pain and weakness during the April 11, 2024, session. R1’s physical therapist stated that they had noticed a bruise on R1’s face, were advised by R1 that they had fallen, and reported the fall to the facility. R1’s responsible party stated that on April 8, 2024, shortly after 12:00PM, they visited R1 at the facility and found that R1 was lying in bed, was unable to open their eyes, had difficulty speaking, had a bruise on their left eyelid, and complained of pain when they were touched. R1’s responsible party was told by Staff #1 (S1) that R1 had fallen while trying to go the bathroom and that R1 was not injured, but S1 did not say when the fall occurred or provide additional details. R1’s doctor stated they were not notified of the fall by the facility and per R1’s Primary Care Medical Records, R1’s doctor only learned of R1’s injury on April 18, 2024, when R1’s responsible party told them about it. A facility communication log entry dated April 7, 2024 indicates that at 11:00AM, Staff #2 (S2) reported that R1 was lying on the floor, R1 denied falling, S1 checked R1’s vitals which were normal and noted no bruises or bleeding, R1 refused to go to the hospital, S1 gave R1 Tylenol, R1 went the rest of the day “without any symptoms”, and Staff #3 (S3) was present during this incident as well. Per facility staff, S1 no longer works at the facility and multiple attempts to interview S1 were unsuccessful. S2 remembered seeing R1 on the floor on April 7, 2024, but could not recall any other details from the incident. S2 stated that the last time they saw R1 before the fall was between 8:30AM and 9:00AM. S3 recalled seeing R1 on the floor on April 7, 2024, at 11:00AM, stated that they had last checked on R1 around 10:30AM, and did not recall seeing any injuries on R1. 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 Per R1’s responsible party, on April 9, 2024, R1’s family visited R1 and noted R1 was unable to eat solid food, speak, or open their eyes. On April 10, 2024, R1’s responsible party visited R1, was not told anything by staff about R1 having a fall, and noted R1 could not open their eyes or speak and that every movement R1 made was so painful that R1 screamed. On April 11, 2024, R1’s responsible party visited R1 and noted R1 could not talk, had a new bruise on their right cheek, and was unable to walk. On April 12, 2024, R1’s responsible party visited R1 and noted R1 appeared to be getting worse and requested that R1 be taken to a hospital. Per R1’s Chapman Global Medical Records, R1 was seen in the emergency department on April 12, 2024, with chief complaints of hip and face pain, swelling above the right eye, decreased appetite, and increased pain. Testing revealed a right subdural hematoma (brain bleed) up to 14 millimeters thick, a comminuted (three or more pieces of broken bone) depressed fracture of the right zygomatic arch (cheek bone), but no skull fracture. R1 was determined to need a higher level of care, was admitted for inpatient treatment that same day, and was thereafter discharged to Chapman Care Center on May 1, 2024. Per R1’s Chapman Care Center Medical Records, R1 was admitted for skilled nursing care on May 1, 2024, R1’s diagnoses included traumatic subdural hemorrhage (brain bleed) without loss of consciousness, R1 had hip pain but no hip fracture, and R1 was transferred to Garden Grove Hospital on May 16, 2024, because they needed a higher level of care. Per R1’s Garden Grove Hospital Medical Records, R1 was admitted on May 16, 2024, with a chief complaint of respiratory distress and a history that included subdural hemorrhage (brain bleed), R1 had difficulty breathing, and R1 passed away on May 17, 2024. Based on the information obtained, after R1 fell on April 7, 2024, the facility did not properly report R1’s fall or subsequent change of condition to R1’s doctor and did not have R1 timely medically assessed. Regarding the allegation that facility staff did not ensure that resident was administered their medication(s) as prescribed: it was alleged that on April 11, 2024, R1’s responsible party visited R1 in the morning, stayed with R1 in their room until 7:30PM, noticed R1 had not received their evening medications, inquired with staff and was told the medications should have been given around 5:00PM, and then observed a medication technician hurriedly give R1 their evening medications. Per facility staff, S1, the facility’s medication technician at the time, no longer works at the facility and multiple attempts to interview S1 were unsuccessful. Per R1’s Medication Administration Records for March 2024, two medications, Atenolol (a blood pressure medication) and Simvastatin (a cholesterol medication), were not given for the last three days of the month, but no reason was documented for withholding these medications. Per a facility communication log entry dated April 7, 2024, S1 administered Tylenol to R1 after a fall on that date. 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 R1’s Primary Care Medical Records dated April 18, 2024, do not indicate that these two medications were discontinued or that there were any instructions for withholding these medications and also do not list Tylenol as an ordered medication. R1’s Medication List dated February 29, 2024, also does not list Tylenol as an ordered medication. The information obtained corroborated that facility staff did not administer R1’s medications as prescribed. Regarding the allegation that facility staff offered oxygen to resident without a doctor's order: it was alleged that on April 8, 2024, R1 was seen with an oxygen tank in their room and S1 stated they had tried to give R1 oxygen because R1 could not breath. R1’s Medication List dated February 29, 2024, and R1’s Primary Care Medical Records do not include orders for oxygen. However, per a facility communication log entry dated April 7, 2024, S1 offered oxygen to R1 and R1 refused the oxygen. Per facility staff, S1, the facility’s medication technician at the time, no longer works at the facility and multiple attempts to interview S1 were unsuccessful. Although R1 refused the oxygen during this particular incident, facility staff still offered R1 a medication for which they did not have a doctor’s order. The information obtained corroborated the allegation. Regarding the allegation that facility staff failed to notify responsible party of injury: it was alleged that on April 8, 2024, R1’s responsible party observed that R1 had sustained an injury at the facility, S1 confirmed that R1 had fallen but was unable to explain how or when R1 had fallen, R1’s responsible party had not been notified of this injury, and S1 stated they did not notify R1’s responsible party of R1’s injury because they did not have the authority to do so. Review of Orange County Regional Office (OCRO) records revealed that the facility did not report this incident or any other incident involving R1 to the OCRO. R1’s doctor stated they were not notified of the fall by the facility and per R1’s Primary Care Medical Records, R1’s doctor only learned of R1’s injury on April 18, 2024, when R1’s responsible party told them about it. A facility communication log entry dated April 7, 2024, indicates that R1’s fall occurred at 11:00AM on April 7, 2024, however it is unknown when this document was given to R1’s responsible party and it does not include all required information such as R1’s identifying information, the physician’s name, findings and treatment, and the disposition of the case. The information obtained corroborated the allegation. 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 repres

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250313083618. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility and obtained and reviewed copies of the resident roster and staff roster. LPA inspected the facility and observed that the fire extinguishers in the assisted living section were last inspected in 2025. However, LPA observed two fire extinguishers in the memory care and two fire extinguishers just outside the memory care that were last inspected in 2023. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. 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.

It was alleged that multiple staff at the facility have been working at the facility without a criminal record clearance. LPA inspected the facility, including the assisted living section and memory care unit, multiple bedrooms, kitchen, medication room, and common areas and observed no health and safety issues. LPA observed 17 staff present, obtained their names and dates of birth, and checked their background clearance status on the Licensing Information System (LIS). Out of the 17 staff present, LPA determined using LIS that staff Sung Ae Byun and Carlota Olguin were not background cleared. AD confirmed neither had been background cleared and that Sung Ae Byun had started working at the facility on March 3, 2025, and Carlota Olguin had started working at the facility on March 5, 2025. LPA reviewed the facility’s staff roster and staff schedule and did not note any additional background clearance issues. 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. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Michelle Song and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 10:45AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and 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 residents. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 114 degrees in the 10 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid and are due today. At about 12:00PM, LPA reviewed 10 resident files and 10 staff files, interviewed 5 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. CONTINUED 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 During the inspection, LPA and AD observed the following: based on Guardian records and interview, Staff #1 (S1) is background cleared but is not associated to the facility and has been working at the facility for a long time; based on documents, the facility has been allowing Resident #1 (R1) to store and administer their own medications, but R1's physician's report indicates R1 is not able to store or administer their own medications; and based on observation, the facility's fire extinguishers have not been inspected since 2023. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. 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.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20241023161245. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, and staff schedule. Per the facility’s staff schedule, Staff #1 (S1) Alma Cervantes works at the facility regularly. Per admission from Licensee (LE) Erik Doan, S1 has worked at the facility for more than five days. LPA determined using the Licensing Information System that S1 is not background cleared and has been working at the facility since May 12, 2023, per their staff file. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

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. 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 It was alleged that witnesses observed that the facility had placed 15 to 20 residents in one room, all of whom were wearing only diapers and infected with scabies. 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 did not obtain information corroborating this allegation. LPA interviewed AD who denied the allegation. LPA interviewed two witnesses who did not provide information corroborating this allegation. LPA interviewed five of the residents who, per AD, have received treatment for scabies, but did not obtain reliable information corroborating the allegation due to the residents’ diagnoses of dementia. LPA interviewed six staff who did not corroborate the allegation. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above 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. 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 It was alleged that visitors and family members are not permitted to enter residents’ rooms and that instead residents are brought out to common areas for visits. LPA interviewed AD and one staff who denied the allegation. LPA interviewed two witnesses who did not provide information corroborating this allegation. On November 5, 2024, LPA inspected the facility and observed visitors in resident rooms in the assisted living section of the facility, but did not observe visitors in the memory care unit. LPA has also previously observed visitors in resident rooms in the assisted living section of the facility on multiple occasions. LPA reviewed the facility’s visitation log for October 2024 and noted four memory care residents who had visitors in October 2024. LPA interviewed the visitors for the four residents, three of whom denied the allegation and one of whom did not corroborate the allegation. No information was obtained corroborating the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20241023161245. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster and staff roster. On October 24, 2024, and November 5, 2024, LPA inspected the facility, including 35 resident rooms, and observed black mold under the sinks of the private resident bathrooms in resident rooms 104, 112, 113, 114, and 116 in the memory care unit. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. 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.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Administrator Michelle Song and explained the reason for the visit. During the 10-day visit for complaint #22-AS-20241010093603 LPA observed the following which is not directly related to the complaint being investigated. LPA and the Administrator toured the facility. LPA observed the See Something, Say Something Poster (PUB 475) measures 10 inches by 16 1/4 inches. LPA observed resident room 233 where Resident 1 lives did not have a smoke detector. LPA observed wires hanging from the ceiling where the smoke detector goes. The Administrator reported that Resident 1 is moving to room 321 and the staff is in the process of moving Resident 1's belongings. LPA informed the Administrator all resident rooms are required to have a smoke detector. The Administrator verified that the there is no smoke detector in room 233. Room 233 still has Resident 1's clothes and personal items. LPA interviewed Staff 1 and LPA reviewed the facility Guardian roster. Staff 1 is not associated to the facility. LPA informed the Administrator and Staff 1 that they cannot be at the facility until they are associated to the facility. Staff 1 does have a background clearance but is not associated to the facility. LPA observed Staff 1 leave the facility. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Civil penalties being issued for the deficiencies cited; CCR 87203 and CCR 87355(e)(2). An exit interview was conducted and a copy of the report LIC 809, LIC 809D, LIC 421 IM, LIC 421 BG, provided along with appeal rights.

LPA interviewed the Administrator and staff. LPA reviewed facility documents and records. Facility has 3 stories/levels and a total 170 rooms. The memory care unit has 29 rooms is on the first level and has a secured perimeter. According to the staff schedule there are only two staff members for the whole facility from 10:30 pm until 6:00 am. The facility Administrator reported that there are 3 staff members but it is from 11:00pm until 7:30 am but it is not listed on the schedule. The Administrator reported that the staff members who start at 10:30pm are constantly checking the residents throughout the facility. The facility has multiple levels and wings and is required to have a signal system. Each room has a call button and it goes to a central panel at the front lobby desk. LPA tested the signal system and it is operational. According to CCR 87415 the facility is required to have, 87415(a)(3) In facilities caring for one hundred one (101) to two hundred (200) residents, one employee shall be on call, on the premises; one employee shall be on duty on the premises and awake; and one employee shall be on call and capable of responding within ten minutes. CCR 87415 (a)(5) In facilities required to have a signal system, specified in Section 87 303, Maintenance Operation , at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. Based on CCR 87415, three people shall be at the facility from 10:00 pm to 6:00 am, one person on call on the premises, one on duty awake on the premises and one person shall be located to enable immediate response to the signal system. LPA informed the Administrator that even if the schedule reflected the 3 staff members present from 11:00 pm until 7:30 am the regulatory requirement is not being met because 3 staff members must be present from 10:00 pm to 6:00 am. The preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.

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 in order to issue citations for deficiencies observed during a separate unannounced joint visit made for the initial investigation of the allegations contained in complaint reference number #22-AS-20240925103324. During the visit, LPA observed a cleaning cart in use in the hallway of the facility's memory care unit on the facility's first level. Cleaning cart was observed to contained powdered bleach and bleach in liquid form, both left fully accessible to memory care residents. Additionally, the memory care laundry area's door was found to be unlocked. An uncovered tub of powdered laundry detergent was observed to be present. A type A citation is cited per Title 22 Division 6 of the California Code of Regulations and documented on an attached form LIC809-D. A makeshift table made of a wooden platform with a broken glass cover with a sharp edge accessible, balanced on two refrigerators and one cabinet was also observed to be placed in the memory care secure courtyard. A type A citation is cited per Title 22 Division 6 of the California Code of Regulations and documented on an attached form LIC809-D. An exit interview was conducted and a copy of this report, attached citations along with appeal rights were provided to a facility representative.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a plan of corrections visit following up on the type A deficiency citation issued on August 18, 2024 after two out of three delayed egress exits in the memory care unit were observed to be inoperational. LPA accompanied by administrator toured the memory care unit and observed that no repairs had been conducted on the exits at this time. Delayed egress doors are therefore still not in operation. A type A deficency is cited on this day on an attached form LIC809-D.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701. LPA met with Staff #1 (S1) Man Park and Staff #2 (S2) James Lee and explained the reason for today’s inspection. Administrator (AD) Michelle Song was not present during the inspection. Licensee (LE) Erik Doan appeared via telephone. During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, and requested and reviewed copies of the resident roster, staff roster, and resident files. LPA observed that the two east outside gates from the memory care unit were not alarmed. During today’s inspection, LPA, S1, and S2 inspected the memory care and tested all exit doors, reviewed the facility’s fire clearance and pre-licensing documents, and observed the following: The facility’s memory care unit is located on the first floor. The main delayed egress door is in the center of the memory care unit near the common area and dining room and leads to an elevator and stairs to access the second floor of the facility. Per the facility’s fire clearance and pre-licensing inspection, the main delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the main delayed egress door and observed that it failed to unlock after multiple attempts. CONTINUED 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 The east delayed egress door is the first door on the east side of the memory care unit, at the end of the hallway, and leads to the second east hallway door. Per the facility’s fire clearance and pre-licensing inspection, the east delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the east delayed egress door and observed it to be functioning properly. A few feet further east of the east delayed egress door, in the same hallway and leading to an outside area marked as “Exit” on the facility’s fire clearance, is the second east hallway door. LPA, S1, and S2 tested the second east hallway door and observed that it did not have delayed egress functionality or an alarm, but per the facility’s fire clearance and pre-licensing inspection, the second east hallway door is not required to have delayed egress functionality or an alarm, as the east delayed egress door already serves that function and Room 101 is not a part of the memory care unit. The west delayed egress door is on the west side of the memory care unit in the common area and dining room and leads to an outside courtyard to the west of the memory care unit. Per the facility’s fire clearance and pre-licensing inspection, the west delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the west delayed egress door and observed that it was readily openable without any delayed egress functionality or alarm being triggered. S1, S2, and LE stated that the west delayed egress door is kept open during the day and closed at night to provide fresh air to the memory care unit and allow residents access to the outside courtyard. At the north end of the memory care unit’s outside courtyard, there is the north outside gate. LPA, S1, and S2 observed that the north outside gate is kept lock. Per the facility’s fire clearance, this gate is not to be used as an exit in case of an emergency. Per S2, the fire department did not approve of this door’s use as an emergency exit because it leads to stairs going up. At the south end of the memory care unit’s outside courtyard, there is an outside pathway leading east to the outside of the east side of the memory care unit. At the end of this outside pathway, there is the first east outside gate which is operational and kept unlocked and leads north. LPA, S1, and S2 tested the first east outside gate and observed it to not have delayed egress functionality or a functioning alarm. While the first east outside gate did appear to have an alarm mechanism, the alarm did not function. 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 North of the first east outside gate is an outside pathway leading north. This area is marked as “Exit” on the facility’s fire clearance and can also be reached via the second east hallway door. At the north end of the “Exit” area is the second east outside gate which is operational and kept unlocked and leads north to the outside of the facility. LPA, S1, and S2 tested the second east outside gate and observed it to not have delayed egress functionality or a functioning alarm. While the second east outside gate did appear to have an alarm mechanism, the alarm did not function. LE stated they will immediately repair the main delayed egress door and the west delayed egress door. LE stated they understand that the first and second east outside gates cannot be locked. LE stated that, while the west delayed egress door is an essential part of the facility’s delayed egress system, the west delayed egress door is kept open during the day and closed at night to provide fresh air to the memory care unit and allow residents access to the outside courtyard and staff supervision is used to prevent wandering. In light of the risk of residents wandering from the outside courtyard, licensee stated they will install alarms on the first and second east outside gates and will consult with LPA and the local fire department to determine whether installing a delayed egress system on one of the two east outside gates is necessary and allowable and will install one if it is necessary and allowable or take other measures as required to address the risk of residents wandering from the outside courtyard. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Assistant Administrator (AA) Anna Jung and discussed the purpose of the inspection. Administrator (AD) Erik Doan arrived during the inspection. LPA reviewed Infection Control requirements. At about 10:00AM, LPA and AA conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and 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 residents. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 118 degrees in the 10 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid. At about 1:00PM, LPA reviewed 10 resident files, interviewed 10 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. CONTINUED 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 During the inspection, LPA and AA observed the following: R1 moved in on 01/13/24 but the facility still does not have a Physician's Report for R1; the facility has not been conducting emergency disaster drills; and the licensee did not ensure their licensing fees were paid and has a past-due balance. The facility’s staff files were not available during the inspection and a technical violation was issued. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. 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.

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. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency. On August 24, 2023, during an investigatory follow up visit, Department staff made an unannounced visit to the facility and requested to speak to the Med Tech on duty after being informed Administrator Erik Doan and Licensed Vocational Nurse (LVN) Grace Park were not present. After waiting 15 minutes with no response, Department staff texted Administrator Erik Doan requesting for a status update. After an additional 15 minutes Doan responded that he would return to the facility once done with his meeting and that no one would be interviewed until he was present on site. It was discovered during the investigation process Resident 1 (R1) had left the property on May 21, 2023, unbeknown to the staff. R1 was disoriented and appearing ill out in on the public street shortly after 2:00 AM and was transported to the hospital. It was not until they were admitted to the hospital that Grace Retirement Village was notified of their whereabouts. On May 31, 2023, Resident 1 (R1) was hospitalized following an unwitnessed fall. Emergency Medical Technicians (EMTs) reported R1’s records were unavailable upon arriving to the facility as records were locked inaccessible to staff. The following is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.

did not match. On May 31, 2023, R1 was hospitalized after an unwitnessed fall. R1 was hospitalized at St. Jude Medical Center and was admitted for severe sepsis. At the time of being admitted, hospital staff observed R1 with multiple burns and skin tears across the upper and lower body. Staff interviewed denied observing burns and stated the burns were carpet burns. Pictures taken by hospital staff depict skin tears and burns resulting in blisters over R1’s extremities including arms, fingers and legs. When shown the pictures, Staff 1 (S1) advised investigators carpet burns don’t blister. Hospital records diagnose R1 with a history of dementia but are unclear where/how they came to know R1 had a history of dementia. Emergency Medical Technicians (EMTs) reported R1’s records were unavailable upon arriving to the facility as records were locked inaccessible to staff. EMT personnel interviewed recalled speaking with their partner and saying the arm injury observed on R1 was “definitely not a skin tear” as reported by staff. The responder recalled seeing the resident’s arm as having some sort of burn but could not recall if it was or was not wrapped upon arrival. Although it remains unclear exactly how the resident sustained the injuries, it is clear the injuries sustained occurred while in care at the facility and contributed to the R1’s hospitalization. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.

on April 30, 2022 when R1 started to reside at the facility. Prior to being admitted to the facility, R1 had previously been admitted to two other board and care facilities and eloped from both homes within 24 hours of being admitted. Interviews with facility staff confirmed the facility received R1’s hospital discharge paperwork from Kaiser Hospital on April 29, 2023, at 11:15 AM what is approximately 10 hours prior to R1 residing at the facility. Although the Licensee reported not reading the paperwork and that the hospital had dropped R1 off blindly, interviews with the facility Administrator Hyo Sok Kim disclosed that they were aware of R1’s exit seeking behaviors and combative and believed R1 would be easily controlled using medications. Kaiser Hospital discharge records dated April 14, 2022, confirmed R1’s diagnosis of dementia with behavioral d isturbances and exit seeking behaviors. On May 6, 2022, two of three staff interviewed reported that R1 had become combative with staff and exited the facility memory care unit. At the time of the incident, staffing records show only Staff 1 (S1) was working at the facility memory care unit. After exiting the memory care unit, R1 continued to the facility entrance. At approximately 11:30 AM R1 eloped from the facility unassisted. Despite knowing R1’s history and seeing R1 walk out of the facility, no staff followed behind to provide R1 with supervision when exiting. S2 contacted La Habra Police to report R1 missing at 1:49 PM, approximately three hours after R1 left the facility. On May 4, 2022, R1’s remains were discovered by the San Bernadino Sheriff’s Department (SBSD) after being struck by a vehicle driver on the 10 freeway. The autopsy report obtained lists R1’s cause of death as multiple blunt force injuries, instantaneous. Despite being made aware of R1’s behaviors and history of exit seeking, the facility still chose to admit R1 to the facility as agreed upon per signed admission agreement. By accepting R1 to the facility, the facility agreed to provide care and supervision as necessary to meet R1’s needs. Facility Administrator Hyo Sok Kim admitted she had filled out R1’s paperwork prior to R1 being admitted and assessed. Despite being provided with R1’s history of exit seeking and behaviors, R1 failed to be properly assessed and later it was determined R1 was not a good fit for the facility. Licensee Eric Doan stated the facility had not received R1’s paperwork prior to being admitted and that the hospital had dropped R1 off after hours and on the weekend. This was a false statement as investigation revealed that the facility did in fact received R1’s paperwork prior to R1 being admitted. They were expecting R1 in advance of them being placed with the facility but failed to properly conduct an assessment. CONTINUED ON 9099-C... 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 On May 1, 2022, R1 eloped from the facility at approximately 11:30 AM after becoming agitated with S2. No staff followed behind R1. S2 awaited until 1:49 PM, approximately 3 hours later, to notify La Habra Police R1 was missing. Despite signing the agreement, the facility failed to provide proper supervision resulting in R1 eloping from the facility and dying three days later. Therefore, based on interviews conducted and records reviewed the allegation that Resident went AWOL from the facility due to lack of care and supervision has been deemed Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(e) An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights were left at the facility.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit. LPA De Perio explained reason for visit, met with assistant administrator Anna Jung. On August 22, 2023, LPA De Perio conducted a case management visit to the facility to collect random resident physician reports. Physician reports for resident 1 2, 3, 4, 5, and 6 (R1, R2, R3, R4, R5, R6) were completed and indicated that the same doctor had evaluated residents. The doctor was interviewed and presented with copies of those physician reports. The doctor verified of never seeing R1, R2, R3, R4, R5 and R6, denied of ever signing reports for residents R1, R2, R3, R4, R5, and R6 and stated that the signature had be falsified. For this visit, citations were issued according to Title 22 California Code of Regulations. An exit interview was conducted with assistant administrator Jung. A copy of this report and Appeal Rights were provided.

Upon admission, R1’s physician report dated for May 5, 2023, indicated that R1 was non-ambulatory. R1 began receiving Home Health Services on May 6, 2023, and was discharged from Home Health Services June 5, 2023, due to no further skilled care needed. R1 had several diagnoses such as: Type 2 diabetes mellitus with unspecified complications, major depressive disorder, recurrent, mild unspecified dementia, unspecified severity, history of falling. Interviews conducted with the facility staff stated that R1 liked to walk around the facility but never made any attempts to leave. On June 18, 2023, staff (S1) conducted a room check at 8:30PM and observed R1 was sleeping. S1 returned to R1’s room to conduct a second check between 10:30PM-11:00PM and did not observe R1 in the room. S1 observed that R1’s sliding glass door which led to the street was open. S1 notified staff on duty and La Habra Police Department (LHPD). Per LHPD report dated June 18, 2023, the R1 was found four hours later with facial injuries by Whittier Police Department and taken to the hospital. R1 was hospitalized and upon admission at the hospital, R1 was observed with blunt trauma to face and per-orbital fracture. The following injuries were noted on R1: multiple depressed fractures at the left zygoma, lateral wall of the left orbit, and left maxillary sinus, slightly displaced left orbital floor fracture, left periorbital/facial soft tissue injury, blood products in the left maxillary sinus. It was observed that R1’s face had extensive dark bruising on left temple area, below left eye and on left chin and cheek and multiple scratches/marks around R1’s nose, mouth, chin, and bruising on left side of R1’s nose. Eight days later, the facility submi tted an incident report to Community Care Licensing on June 26, 2023, regarding R1’s June 18, 2023 elopement. On June 23, 2023, an interview was conducted with the facility administrator (AD) who stated that R1 did not have an alarm on their door and was unsure if the facility documented watch logs per resident. The day following the interview, AD provided the Department with a document titled “Watch Log” starting from June 18, 2023, which was the day R1 eloped, and was noted for the times of 6:00AM to 11:00PM. It was observed that there was a staff initial next to every hour. A follow-up interview was conducted with the staff members who had initials on the Watch Log. S1 admitted to never seeing or using a Watch Log, and also denied of initialing a Watch Log document. 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 An interview was conducted with staff 2 (S2) who provided AD the Watch Log, and S2 stated that the log was for the facility’s own personal use and that S2 was unaware it was sent to the Department. S2 then stated the log was made as an example for AD to possibly use in the future. When AD was asked to explain how the log was accidentally sent to the Department, AD stated that AD was unaware if the facility documented room checks, and stated the document was for S2’s personal documentation and was not meant to be disseminated. It was also observed that the document was not accurate because the initials of S1 indicated that S1 checked on R1 between 9:00 PM and 10:00 PM, however an interview was conducted with S1, who denied the of initiating a document. This document was later determined to be a false document that was completed by S2, therefore it became a concern that there may be additional documents that were provided that also may have been falsified. Upon additional investigation involving interviewing R1’s physician, it was determined that R1’s physician’s report dated for May 5, 2023 was falsified. The report had the physician’s name handwritten on it with the exam date of May 5, 2023, however the indicated physician confirmed that the report was not signed by him as R1 had not been evaluated by the physician until June 18, 2023. Per falsified physician report provided by the facility dated May 5, 2023, R1 was reported to only have Mild Cognitive Impairment, is unable to leave the facility unassisted, is non-ambulatory, and that R1 did not have dementia. However, the Pasadena Care Center discharge summary dated for May 4, 2023 and the admission summary from Whittier Hospital dated for June 19, 2023, indicated that the R1 is diagnosed with dementia. During the investigation, evidence shows that the physician’s report was falsified, because the physician denied of ever evaluating R1 on May 5, 2023 and that the physician report the facility presented did not align with the diagnoses specified on the Pasadena Care Center documents. It was determined that R1 did not have a medical exam prior to being admitted to the facility, therefore, the facility was unaware of the level of care R1 required, resulting in R1 eloping and sustaining multiple injuries. Based on interviews which were conducted by the Department, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED. 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 See LIC9099D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49. An exit interview was conducted with assistant administrator Jung. A copy of this report, and appeal rights were provided and explained.

On both dates the alarm rang when the exit was pushed and after pushing for 10 seconds the door opened. LPA observed as staff responded to the delayed egress alarm within three to five seconds. During the course of the interviews AD stated that the alarms get tested once a month. Per AD staff redirect residents who cannot leave unassisted, and staff try to provide what the residents need in order to de-escalate the situation. However, records reviewed by LPA Ramirez included the Unusual Incident/Injury Reports (UIIRs) dated 05/02/22 for Resident 1 (R1), dated 09/17/22 for R2 and dated 06/19/23 for R3. Per UIIRs R1 eloped from the facility on 05/01/22, R2 eloped from the facility on 09/17/22 and R3 eloped from the facility on 06/18/23. The facility neglected the residents’ care and supervision as it was unsafe for all three residents to leave the facility unassisted. Even though the facility has security systems, the security systems have proved inadequate as evidence by multiple residents eloping from the facility unsupervised. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility has inadequate security systems is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with AD Santos and a copy of this report along with the Appeal Rights were provided at the time of this visit.

On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced joint visit with IB Investigator Hector Quintanar for the purpose of conducting additional interviews for Complaint Control No. 22-AS-20230718165749 and 22-AS-20230531150652. LPA Tirre met with Licensee Erik Doan and LVN Grace Park and explained the reason for today’s visit. During the visit, LPA, IB Investigator, and Licensee toured inside and outside physical plant of facility. LPA Tirre and Investigator Quintanar interviewed staff and resident. LPA requested and reviewed copies of the resident roster and staff roster. During today's visit LPA observed broken glass on the ground outside of Memory care patio walkway. LPA observed feces on walkway wall. LPA also observed Memory care outside walkway had unsecured gate which led to back lot location where facility vehicles are parked. The following 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.

On the visit of 06/07/2023 LPA Mendivil requested a copy of the full liability insurance policy from Licensee Eric Doan. LPA Mendivil attempted to verify the authenticity of the liability insurance certificate by reaching out to the insurance company and requesting a full copy of the policy from the facility. As of 08/31/2023 LPA Mendivil was unable to ascertain the authenticity of the liability insurance certificate, therefore based on the records reviewed and interviews the allegation that facility does not maintain required liability insurance 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.