306005636-4-16-2021-22-AS-SSAS-C362EY-20210518172043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 04/16/2021
Date Signed: 04/16/2021 12:56:29 PM

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
07/13/2020 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200713102906

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:	ZIP CODE:	92868
CAPACITY:	153	CENSUS: 53	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Briana Boyd		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff failed to assist resident with meal services
Licensee is charging fees outside the admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michelle Reed contacted the facility to issue the findings of this complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the findings with Interim Administrator Briana Boyd. The Department received a complaint that facility staff failed to assist resident with meal services and the Licensee is charging fees outside the admission agreement. R1 was admitted into the facility on 9/28/19. Interviews were conducted with R1 and staff. Facility records and admission agreement for R1 were also reviewed.

Allegation # 1- Facility failed to assist resident with meal services

Based on complaint intake, reporting party stated that R1 was not escorted to breakfast, lunch and dinner by staff. Records reviewed disclosed that from 12/12/19-3/22/20, R1 refused to be taken to the dining room 51 times. R1 was given a free tray service or at R1’s preference, order take out. Meal logs reviewed from 7/6/20-7/21/20 disclosed that R1 was taken to breakfast and did not refuse service. According to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200713102906

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: 04/16/2021

NARRATIVE

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interviews conducted, R1 would often not want certain staff to escort R1 to the dining room and if those staff showed up R1 would refuse meals. R1 would also refuse if not taken to meals 10 minutes before meals were served.

Allegation #2- Licensee is charging fees outside the admission agreement

R1’s admission agreement was reviewed as well as the facility fee schedule. R1 did not want to pay to be escorted to dinner as R1 did not go to the dining room for dinner. R1 did not reach out to the facility Administration and adjusted his rent on his own. On 7/22/20 Administrator sat down with R1 and went over all services and charges on R1’s admission agreement. Adjustments were made and agreement was made and R1 signed the agreement.

Based upon interviews and a review of R1's records, these allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Administrator Briana Boyd is reminded that all Admission agreements should be kept current and addendums completed in a timely manner. Admission agreements shall also be clear on what additional service rates are being charged.

An exit interview was conducted with Ms. Boyd via telephone and a copy of this report was provided via email for signature. Ms. Boyd agreed to sign and return report.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

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