306005636-10-19-2020-22-AS-SSAS-BUSVM6-20201027163302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 10/19/2020
Date Signed: 10/19/2020 10:12:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2020 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200529161650

FACILITY NAME:	MAINPLACE SENIOR LIVING		FACILITY NUMBER:	306005636
ADMINISTRATOR:	GOLLIHAR, JEFFERY		FACILITY TYPE:	740
ADDRESS:	1800 1832 W. CULVER AVENUE		TELEPHONE:	(714) 978-2534
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	153	CENSUS: 58	DATE:	10/19/2020
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Executive Director Michael Marion		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not clean the resident's room.
Facility did not provide resident basic laundry service.
Facility staff not assisting resident with self administered medication.
Facility staff not treating residents with dignity and respect.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

As precautionary measures during the Coronavirus 2019 pandemic, Licensing Program Analyst (LPA) Albert Marin made an unannounced video teleconference visit to deliver the findings on a complaint investigation. LPA met with Executive Director Michael "Mike" Marion and stated the purpose of the visit and the findings of the investigation.

On May 29, 2020, The Department received a complaint alleging that the facility did not clean the resident’s room. Based on observation and interviews, Five out of six residents randomly interviewed stated that they did not have any issue or concerns with the cleanliness of their room. One resident stated that there had prior issue with cleanliness, and it was addressed by the facility. During the initial visit via video teleconference, LPA checked random resident’s room and observed the area to be maintained and in order. LPA also observed common areas and they were unremarkable.

(Page 1/2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 22-AS-20200529161650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAINPLACE SENIOR LIVING	FACILITY NUMBER: 306005636
	VISIT DATE: 10/19/2020

NARRATIVE

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 second allegation in the complaint stated that the facility did not provide resident basic laundry services. Based on file review, admission agreement stated that under basic services laundry service is included for one white and one-color load per week, and there is additional cost of $10.00 per load. During the tour of the facility, LPA observed the a working laundry unit in the facility. There was a posted schedule of their use. Based on random interviews, four residents denied having issues with the laundry services offered by the facility. One resident claimed laundry is done outside the facility with no issues.

The third allegation in the complaint stated that facility staff not assisting resident with self administered medications. Based on file review, some residents were identified and evaluated to be able to manage their own medications. These medications were kept and independently managed by the residents. In the allegation, it was stated that assistance was sought to clarify an information on the medication label. Staff was informed and assistance was rendered, with no document untoward incident. All random interviews with five residents revealed no pending issues or concerns with the timeliness of medication management of the facility.

The last allegation in the complaint stated that facility staff not treating residents with dignity and respect. Based on random interviews, eight out of eleven witnesses stated that they did not witness any forms abuse from the facility staff. One staff member was identified to a personality and behavior that other witnesses considered to be rough, lack of respect and consideration to the residents.

Based on the information gathered during the investigation conducted which involved interviews and review of all documents obtained, The Department is unable to ascertain if the four allegations mentioned above occurred as reported. Although each allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. Thus, all four allegations in this complaint are deemed UNSUBSTANTIATED.

LPA Marin conducted an exit interview and read this report with ED Marion. LPA will provide copy of this report via email; and ED Marion agreed to acknowledge their receipt.

(Page 2/2)

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2