Grace Retirement Village

FACILITY EVALUATION REPORT

COMPLAINT INVESTIGATION REPORT

The inspection identified multiple deficiencies across several critical areas, including resident safety, staff competency, and recordkeeping. Key issues include improper water temperature in resident bathrooms, outdated staff health screenings, and significant gaps in required staff training (dementia, first aid, medication). All cited deficiencies are classified as Type B, indicating potential but not immediate, direct risks to residents.

This unannounced Case Management - Incident inspection followed up on multiple elopement incidents involving Resident #1 (R1). The inspection cited two Type A deficiencies related to inadequate care and supervision, which directly contributed to R1's safety risks. Additionally, two Type B deficiencies were cited for failing to properly report R1's elopement on October 30, 2025.

COMPLAINT INVESTIGATION REPORT

This unannounced Case Management inspection was conducted by LPA Sean Haddad to review resident files. The inspector reviewed the resident and staff rosters and facility records. No deficiencies were cited per Title 22 Division 6 of the California Code of Regulations.

This was a Complaint Investigation regarding mold in the facility. The investigation substantiated the allegation, finding visible black mold in the kitchen, first floor memory care, and second floor chapel. The primary deficiency cited is a failure to maintain a clean, safe, and sanitary environment, resulting in two Type B citations.

This was an unannounced POC inspection to verify the correction of deficiencies from a previous Case Management inspection. One Type A violation regarding liability insurance was cited because the facility failed to provide proof of adequate coverage. A previously cited Type A violation concerning delayed egress was confirmed as cleared.