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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 07/26/2022
Date Signed: 11/10/2022 11:22:47 AM

Unsubstantiated


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
09/29/2020 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200929093348
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: 73DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Phat NguyenTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to escort Resident #1 to breakfast causing resident to faint
Staff failed to provide first aid to Resident #1
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 the Administrator, staff, and resident as well as documentation from the facility. The following was determined: R1 was admitted into the facility on 9/28/19. Records reviewed disclosed that R1 is non-ambulatory, has capacity for self care and stores and administers his own medications. The allegations allege that on 9/27/20, staff failed to escort R1 to breakfast. According to staff interviewed, R1 refused to go to breakfast. R1 administered himself his medications without food which caused R1 to faint and fall resulting in a cut on R1’s leg. When staff were later told of the incident staff did not administer first aid as R1 refused to be assessed for any injuries. Staff asked R1 if he would like go to the hospital or to the doctor's. R1 stated "no, I am going to see my doctor tomorrow and will be assessed then"
Based upon interviews, the allegations above are unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Phat Nguyen.


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: 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.
LIC9099 (FAS) - (06/04)
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