Inspection Reports for
Grace Retirement Village

CCR 87303(e)(2) Faucets used by residents must deliver hot water regulated between 105 and 120 degrees F. One faucet in Room 123 tested at 122 degrees F, posing a potential safety risk.

CCR 87411(f) Personnel health screenings were incomplete or outdated for staff S3, S4, and S9, posing a potential health and safety risk.

HSC 1569.625(b)(1) Staff S5, S6, and S9 lacked records of the required 40-hour initial training, posing a potential health and safety risk.

HSC 1569.625(b)(2) Staff S2, S3, S4, S7, and S8 lacked records of the required 20-hour continuing training, posing a potential health and safety risk.

CCR 87411(c)(1) Staff S4 and S5 did not have current first aid certificates, posing a potential health risk.

HSC 1569.626(a)(1) No staff received the required 12 hours of dementia initial training or 8 hours of dementia continuing training, posing a safety risk.

CCR 87458(c)(7) Physician reports for residents R1 through R10 lacked required behavioral expression descriptions, posing a safety risk.

CCR 87463(a) Appraisals for residents R2, R6, R7, R8, R9, and R10 were more than a year old, posing a safety risk.

CCR 87507(c) Admission agreement for resident R2 was blank, posing a potential personal rights risk.

HSC 1569.69(a)(1) Medication technician S8's training records lacked documentation of hours and type of training; S9 had no medication training, posing a health risk.

CCR 87464(f)(1) Basic services shall include care and supervision. The licensee did not ensure Resident #1 received care and supervision to meet their needs, resulting in a second elopement and hospitalization, posing an immediate safety risk.

CCR 87211(a)(1)(D) Reporting requirements mandate reporting incidents threatening resident safety. The licensee did not report Resident #1’s elopement on October 30, 2025, posing a potential safety risk.

CCR 87633(k) Hospice Care of Terminally Ill Residents: The licensee did not maintain complete centrally stored medication records and medication administration records for residents receiving hospice care, posing a potential health risk.

CCR 87465(i) Incidental Medical and Dental Care: The licensee did not timely dispose of expired medications, posing a potential health risk to persons in care.

CCR 87631(a)(3)(B) Healing Wounds: The licensee did not ensure documentation of wound care from hospice care or facility staff for a resident with a stage 1 pressure ulcer, posing a potential health risk.

CCR 87303(a) Maintenance and Operation: The facility was not clean, safe, sanitary, and in good repair as black mold was present in the kitchen, first floor memory care, and second floor chapel areas. This poses a potential health risk to persons in care.

Health & Safety Code section 1569.605 requires liability insurance covering injury to residents and guests in specified amounts. The facility has not provided proof of such insurance, posing an immediate personal rights risk to up to 93 persons in care.

CCR 87208(a) Plan of Operation was not followed as the licensee did not notify or obtain approval for a new memory care on the third floor, posing an immediate safety and personal rights risk to persons in care.

HSC 1569.605 The licensee did not maintain liability insurance covering injury to residents and guests in the required amounts due to sub-limits on typical injuries, posing an immediate personal rights risk to up to 93 persons in care.

CCR 87211(a)(1)(B) Reporting Requirements were not met as the licensee did not submit a written report to the licensing agency within seven days of a serious injury occurrence. The licensee failed to report Resident #1's femur fracture to the OCRO, posing a potential safety risk to persons in care.

CCR 87465(a)(1) The licensee did not ensure Resident #1 received proper wound assessment and care for their unstageable pressure injury, posing an immediate health risk. A civil penalty was assessed.

California Code of Regulations § 87464(f)(1) Basic Services was violated due to lack of proper care and supervision of a resident.

The licensee was cited under California Code of Regulations § 87464(f)(1) for failing to provide adequate supervision and basic services, resulting in resident wandering and injuries.

Resident Records 87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (b) Each resident’s record shall contain at least the Physician Report, Appraisal/Needs and Services Plan, Personal Rights, Admission Agreement, I.D. and Emergency Information, Centrally Stored Medication Destruction Record, and Safeguards for Cash Resources. The files for residents R1-R5 lacked I.D., Emergency Information, Centrally Stored Medication Destruction Record, and Safeguards for Cash Resources.

CCR 87615(a)(1) Prohibited health conditions. The licensee retained a resident with an unstageable pressure injury and failed to seek a higher level of care, posing an immediate health and safety risk.

CCR 87465(a)(1) The licensee did not notify the resident's doctor or obtain medical assessment after the resident's fall and change of condition, posing an immediate health risk.

CCR 87465(a)(4) The licensee did not ensure the resident received assistance with medications and failed to give prescribed medications for multiple days, posing an immediate health risk.

CCR 87465(a)(5)(A) The licensee offered oxygen and gave Tylenol to the resident without physician authorization, posing an immediate health risk.

CCR 87211(a)(1) The licensee did not provide a written report of the resident's fall to the licensing agency or responsible party within seven days, posing a potential health risk.

CCR 87355(e)(1) Criminal Record Clearance was not met as S4, S5, and S7 were not background cleared prior to working at the facility, posing an immediate safety risk. Civil penalty was assessed.

CCR 87412(a) Personnel Records requirement was not met as the licensee did not maintain personnel records for 4 staff, posing a potential safety risk to persons in care.

CCR 87303(a) Maintenance and Operation (a): The facility was not clean, safe, sanitary, and in good repair at all times as four fire extinguishers were not inspected within the last year. This poses a potential safety risk to persons in care and a civil penalty was assessed.

CCR 87355(e)(1) Criminal Record Clearance was not obtained prior to staff working at the facility. Two staff members worked without clearance, posing an immediate safety risk.

CCR 87355(e)(3) Criminal Record Clearance: Staff member S1 is background cleared but not associated with the facility, posing a potential safety risk.

CCR 87465(a)(1) Incidental Medical and Dental Care Services: Resident R1 is allowed to store and administer their own medications despite physician's report indicating inability to do so, posing a safety risk.

CCR 87303(a) Maintenance and Operation: Fire extinguishers have not been inspected since 2023, posing a potential safety risk. Civil penalty assessed.

CCR 87303(a) requires the facility to be clean, safe, sanitary, and in good repair at all times. The licensee failed to ensure the memory care unit was free from mild bad odors, including urine and feces, posing a potential personal rights risk. A civil penalty was assessed.

CCR 87355(e)(1) requires all individuals to obtain a California criminal record clearance prior to working in a licensed facility. The licensee did not have Staff #1 background cleared before working for at least five days, posing an immediate safety risk.

CCR 87468.1(a)(1) Personal Rights of Residents were not met as memory care residents were kept only in diapers and a shirt overnight, compromising their dignity and posing a personal rights risk.

CCR 87303(a) Maintenance and Operation: The facility was not clean, safe, sanitary, and in good repair as black mold was observed under the sinks in resident rooms 104, 112, 113, 114, and 116. This poses a potential health risk to persons in care.

CCR 87415(a)(5) requires at least one night staff person to be located to enable immediate response to the signal system. The facility does not have a staff person monitoring the signal system to provide immediate response, posing an immediate health and safety risk.

CCR 87555(b)(8) requires all food to be of good quality and not expired. The facility stored 49 boxes of expired cereal, posing an immediate health and safety risk to residents.

CCR 87355(e)(2): Staff 1 has a background clearance but is not associated with the facility, posing an immediate health and safety risk to residents.

CCR 87203: Resident 1's room 233 did not have a smoke detector installed, posing an immediate health and safety risk to residents.

CCR 87705(f)(2) requires toxic substances such as cleaning supplies to be stored inaccessible to residents with dementia. Cleaning supplies were left unattended and accessible in the memory care unit, posing an immediate risk to residents.

CCR 87303(a) requires the facility to be clean, safe, sanitary, and in good repair at all times. A makeshift table with a broken glass cover was found in the memory care secure courtyard, creating an immediate safety hazard.

CCR 87202(a) Fire clearance was not maintained as two out of three delayed egress doors were not functioning and one door was kept open, posing an immediate safety risk. This is a repeat deficiency from August 18, 2024.

CCR 87202(a) Fire Clearance: The licensee was not following its approved fire clearance because two out of three delayed egress doors were not functioning as required and the west delayed egress door was kept open, posing an immediate safety risk to persons in care.

HSC 1569.69(a)(1): Staff S1 and S2 did not have documented medication technician training, posing a potential health risk to persons in care.

CCR 87405(a): The facility did not have a qualified and currently certified administrator designated, posing a potential safety risk to persons in care.

CCR 87458(a) Medical Assessment: The facility did not have a Physician's Report for resident R1 who moved in on 01/13/24, posing a potential health risk.

HSC 1569.695(c) Other Provisions: The facility has not been conducting emergency disaster drills as required, posing a potential safety risk.

CCR 87156(a) Licensing Fees: The licensee did not ensure licensing fees were paid and has a past-due balance, posing a potential risk to persons in care.

A technical violation was issued due to the facility's staff files not being available during the inspection.

CCR 87464(f)(1): Basic services including care and supervision were not met as Resident 1 eloped from the facility on May 21, 2023, without staff knowledge, posing an immediate risk to resident health and safety.

CCR 87405(a): The licensee failed to have a qualified designated substitute administrator on August 24, 2023, posing a potential risk to resident health and safety.

CCR 87755(b): The licensee failed to ensure provisions for private interviews with staff on August 24, 2023, risking residents' personal rights and safety.

CCR 87469(c)(1): The licensee failed to ensure resident records were available to emergency personnel as records were locked and inaccessible, posing a potential risk to resident health and safety.

CCR 87464(f)(1) Basic Services. Licensee failed to ensure Resident 1 was receiving care and supervision which resulted in Resident 1 sustaining a burn from an unknown cause while in care. This poses an immediate health and safety risk to residents.

Title 22 Regulation 87464(f)(1) pertaining to Basic Services deficiency has been cleared after timely correction and in-house training.

Title 22 Regulation 87411(a) pertaining to Personnel Requirements deficiency has been cleared after timely correction and ensuring sufficient personnel.

Title 22 Regulation 87456(a) pertaining to Evaluation of Suitability for Admissions deficiency has been cleared after timely correction.

Title 22 Regulation 87405(h)(1) pertaining to Administrator Qualifications and Duties deficiency has been cleared after timely correction.

Title 22 Regulation 87207 pertaining to False Claims deficiency has been cleared after timely correction.

Title 22 Regulation 87506(a) pertaining to Resident Records deficiency has been cleared after timely correction.

CCR 87456(a) Evaluation of Suitability for Admission was not met as the facility did not evaluate Resident 1 for suitability prior to acceptance, posing an immediate risk to resident health and safety.

CCR 87405(h)(1) Administrator qualifications and duties were not met as the facility failed to ensure regulatory compliance regarding acceptance and supervision of Resident 1, posing an immediate risk to resident health and safety.

CCR 87207 False Claims regulation was violated as the licensee provided false statements about receiving Resident 1’s paperwork prior to admission, posing an immediate risk to resident safety.

CCR 87506(a) Resident Records regulation was not met as the licensee failed to maintain a complete and current record for Resident 1, including incomplete appraisal and unsigned physician report, posing a potential risk to resident health and safety.

Basic Services (f) Basic services shall include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). The facility failed to provide care and supervision to R1, resulting in R1 eloping and dying. This poses an immediate risk to residents.

CCR 87464(f)(1) Basic services shall include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). The facility did not obtain a proper medical evaluation for the resident, resulting in inadequate supervision and the resident wandering out of the facility and sustaining injuries. This poses an immediate health and safety risk to residents in care.

CCR 87207 False Claims: No licensee, officer, or employee shall make or disseminate false or misleading statements regarding the facility or its services. The physician denied evaluating residents R1-R6 and stated the signatures were falsified, posing immediate health and safety risks.

CCR 87458(a) Medical Assessment: The licensee must obtain a physician-signed medical assessment prior to resident acceptance. The facility did not obtain physician reports or medical evaluations for residents R1-R6, posing immediate health and safety risks.

1569.605 Health and Safety. The facility failed to provide a full liability insurance policy meeting regulatory requirements by the POC due date. The policy submitted listed a different entity and had exclusions not meeting required coverage amounts.

87303(a) Maintenance and Operation. Broken glass and feces were found unattended in the Memory Care Unit. The facility cleaned the area and submitted proof of correction, clearing this deficiency.

87705(h) Care of Persons with Dementia. The facility gate leading to the back lot lacked a functioning self-closing latch by the POC due date. The submitted proof did not meet requirements, and the deficiency remains.

CCR 87464(f)(1) Basic services including care and supervision were not met as three residents left the facility unassisted. The facility neglected residents' care and supervision, making it unsafe for them to leave unassisted.

CCR 87411(a) Personnel Requirements - General: Facility personnel were not sufficient in numbers and competent to meet resident needs. An incident report showed a resident left the facility unassisted despite being unable to do so.

CCR 87303(a): The facility was not kept clean and safe as broken glass was observed unattended on the ground and feces smeared on the wall accessible to dementia residents, posing immediate health and safety risks.

CCR 87705(h): The facility gate leading to the back lot lacked a functioning self-closing latch, failing to protect the safety of residents in the dementia care area.

HSC 1569.605 requires all residential care facilities for the elderly to maintain liability insurance covering injury to residents and guests of at least $1,000,000 per occurrence and $3,000,000 in total annual aggregate. The facility failed to provide the requested full liability insurance policy, posing a potential threat.

CCR 87458(a) Medical Assessment: Facility failed to obtain physician reports for residents R1, R2, R3, and R4. This poses an immediate health and safety risk to residents in care.

CCR 87468.2(a)(1) Additional Personal Rights: Facility took possession of six resident cell phones and placed them in a plastic container in the staff office. This poses a potential health and safety risk to residents in care.

CCR 87506(c)(1): All information and records obtained from or regarding residents shall be confidential. The licensee and employees shall only disclose confidential information with resident or representative consent. The facility failed to provide requested documents and did not show proof to the Licensing Program Analyst.

CCR 87411(a) Personnel Requirements - Facility personnel were not sufficient in numbers to provide necessary services. A resident left the facility unassisted despite being unable to do so per physician report.

CCR 87506(c)(1): All information and records obtained from or regarding residents shall be confidential and only released with written consent. The facility failed to provide requested documents or contact the requestor for an extension, posing a risk to persons in care.

California Code of Regulations Section 87506(e) requires original resident records to be retained for at least three years following termination of service. The facility was unable to locate and provide the requested resident records, posing a risk to health, safety, and personal rights.

Facility staff changed resident’s mailing address without authorization, but this was found to be unfounded as it was done to notify Social Security Administration per policy.

Facility did not notify responsible party of resident’s change in condition, but this allegation was found to be unfounded with extensive documentation of notifications.

Facility did not meet resident’s needs, but evidence showed adequate palliative care was provided, so the allegation was unsubstantiated.

Facility staff did not follow doctor’s orders, but no evidence of non-observance was found besides a verbal disagreement with family, so the allegation was unsubstantiated.

Health and Safety Code section 1569.312 requires monitoring residents to ensure their safety. Resident R1 was able to leave the secure memory care unit unattended, violating this requirement.

California Code of Regulations Section 87303(a) requires the facility to be safe and in good repair. The memory care unit floor material bunches up and creases, creating a fall hazard.

CCR 87608(a)(3) requires a written physician order for postural supports in the resident's record. Half bed rails were in place without such an order at the time of the fall on 01/18/2023, posing a potential risk to resident safety.

CCR 87211(a)(1)(B) requires submission of a written report within seven days for serious injuries. The licensee failed to submit an incident report prior to the inspection on 01/28/2023, posing a potential risk to resident safety.

CCR 87506(c)(1): The facility did not provide requested resident documents after a formal request, violating confidentiality requirements. This failure poses a potential risk to persons in care.

CCR 87468.2(a)(8) Additional Personal Rights: The licensee did not ensure Resident #1 was free from neglect, punishment, and physical abuse when a staff member tied the resident to their wheelchair, posing an immediate personal rights and safety risk.

CCR 87203 Fire Safety - A wheelchair was blocking an exit gate door on the first floor by Memory Care, and the gate door was tied with a cloth at the top, creating an immediate health and safety risk to residents.

Kitchen refrigerator temperature tested at 45 F degrees and freezer tested at 5 F degrees. All stairways lacked evacuation chairs which must be corrected.