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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005636
Report Date: 11/10/2022
Date Signed: 11/10/2022 11:25:11 AM


Document Has Been Signed on 11/10/2022 11:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
306005636
ADMINISTRATOR:PHAT T. NGUYENFACILITY TYPE:
740
ADDRESS:1800 1832 W. CULVER AVENUETELEPHONE:
(714) 978-2534
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:153CENSUS: 81DATE:
11/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator Rhon HipolitoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst Michelle Reed arrived at the facility to conduct a case management visit. Upon arrival, LPA met with Designated Administrator Rhon Hipolito. The visit was conducted to amend Complaint #22-AS-20200929093348. The amendment was conducted to add additional information. The finding of Unsubstantiated was not changed.

An exit interview was conducted and a copy of this report was provided to Rhon Hipolito.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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