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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 08/10/2022
Date Signed: 08/11/2022 08:44:44 AM

Substantiated


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
01/02/2021 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210102174521
FACILITY NAME:MAINPLACE SENIOR LIVINGFACILITY NUMBER:
306005636
ADMINISTRATOR:MICHAEL MARIONFACILITY TYPE:
740
ADDRESS:1800 1832 W. CULVER AVENUETELEPHONE:
(714) 978-2534
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:153CENSUS: 75DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Phat NguyenTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility dryers were nonoperational and resident laundry not washed
Resident tv and cable were nonoperational
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to deliver the findings for the above complaint allegations. Upon arrival, LPA met with Wellness Director Kim Mims and Phat Nguyen. The investigation consisted of interviews with Administrator Mike Marion, staff, and residents as well as documentation from the facility. The following was determined:
Administrator Mike Marion admitted to LPA that the dryers were non-operational on 12/2/20 and that they were repaired on 12/4/20. At that time, residents were instructed that laundry would be delayed as there was a backup. Mr. Marion stated that residents were told that they could take their laundry to a laundry mat if it was something urgent that needed washed. He stated that due to Covid there was a delay in having the dryers repaired. On 12/31/20, the cable at the building was nonoperational. Emails provided disclosed that two technicians came out to the facility on 1/2/21 and the issue was still not resolved. Due to the holiday it was not fixed until 1/5/21 by a Technical Support Representative.

See LIC9099D for cited deficiencies.An exit interview was conducted and a copy of this report and appeal rights were provided to Phat Nguyen.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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 4
Control Number 22-AS-20210102174521
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
87307(3)
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Personal Accommodations and Services-
Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.

This requirement was not met as evidenced by:
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Licensee agrees to have all dryers inspected and repaired as soon as issues arise. Proof of understanding will be provided by
8/12/22.
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According to Administrator Mike Marion, the dryers at the facility were nonoperational. Dryers were nonoperational on 12/2/21. residents were told by staff to take their laundry to a laundry mat to be washed and dried. Dryers were repaired by 12/4/20. This posed a potential health risk and personal rights risk to residents in care.
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Type B
08/12/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation-
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services.

This requirement was not met as evidenced by:
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The Licensee understands that other activities should be offered if the cable is not working in resident rooms. Licensee agrees to notify families and residents when there is an issue with the cable as the cable is included in the resident rent. Proof of understanding will be provided by 8/12/22.


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On 12/31/20, the cable at the building was nonoperational and was not repaired for 4 days. This poses a potential personal rights risk to residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
01/02/2021 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210102174521

FACILITY NAME:MAINPLACE SENIOR LIVINGFACILITY NUMBER:
306005636
ADMINISTRATOR:MICHAEL MARIONFACILITY TYPE:
740
ADDRESS:1800 1832 W. CULVER AVENUETELEPHONE:
(714) 978-2534
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:153CENSUS: 75DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Phat NguyenTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Food Menu's are not followed
Administrator not returning phone calls in a timely manner to responsible parties
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to deliver the findings for the above complaint allegations. Upon arrival, LPA met with Administrator Phat Nguyen. The investigation consisted of interviews with Administrator Mike Marion, staff, and residents as well as documentation from the facility. The following was determined:

During the months of December 2020 and January 2021, Covid Precautions were followed and the dining room at the facility was closed. Food was being delivered via tray service. Food menu’s were followed as close as possible, however sometimes adjustments needed to be made. Residents had an alternate menu to choose from if they did not like what was being served. Quesadilla’s were listed on the menu for December of 2020. If residents did not like Quesadilla’s there was an alternate menu. Administrator Mike Marion was out of the office from 12/19/20 through 12/29/20. Calls were not returned during that time. When he returned calls were returned. Licensee is reminded that if the Administrator is unavailable for an extended period of time, an outgoing message should be left saying such and there should be someone available to assist residents and families with questions or concerns.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20210102174521
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: 08/10/2022
NARRATIVE
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Based upon the review of records and interviews, 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.

An exit interview was conducted and a copy of this report and appeal rights were provided to Phat Nguyen.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4