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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 06/10/2023
Date Signed: 06/10/2023 02:36:36 PM

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
03/17/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230317144713
FACILITY NAME:MAINPLACE SENIOR LIVINGFACILITY NUMBER:
306005636
ADMINISTRATOR:RHONWINN HIPOLITOFACILITY TYPE:
740
ADDRESS:1800 1832 W. CULVER AVENUETELEPHONE:
(714) 978-2534
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:153CENSUS: 100DATE:
06/10/2023
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Anthony Sanchez - Medication TechnicianTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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9
Facility failed to administer medication
Facility failed to provide resident's record to emergency personnel
Facility failed to provide care and supervision to resident


INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation regarding the above allegations. LPA Velazquez gained entry into the facility and met with Medication Technician Anthony Sanchez and explained the purpose of the visit. LPA Velazquez spoke with Executive Director (ED) Rhon Hipolito on the phone to inform ED of the purpose of today's visit.

On today's visit LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also requested copies of facility and resident records. During the course of the investigation the following was revealed. LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed copies of facility and resident records. The records reviewed included email communication between the facility and the Reporting Party (RP), Resident Preplacement Appraisal Information, Physician's Report, Resident (R) #1's Veterans Administration (VA) Long Beach medical records , California Assisted Living Waiver (ALW) Program Individual Service Plan (ISP). Admission Agreement, ECHO Hospice of Orange County records, Mainplace Senior Living,
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
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 6
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
03/17/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230317144713

FACILITY NAME:MAINPLACE SENIOR LIVINGFACILITY NUMBER:
306005636
ADMINISTRATOR:RHONWINN HIPOLITOFACILITY TYPE:
740
ADDRESS:1800 1832 W. CULVER AVENUETELEPHONE:
(714) 978-2534
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:153CENSUS: 100DATE:
06/10/2023
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Anthony Sanchez - Medication TechnicianTIME COMPLETED:
02:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to provide a clean and sanitary environment
Resident's call button is inoperable
Facility is not following reporting requirements
Facility does not answer phone calls
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation regarding the above allegations. LPA Velazquez gained entry into the facility and met with Medication Technician Tony Sanchez and explained the purpose of the visit. LPA Velazquez spoke with Executive Director (ED) Rhon Hipolito on the phone to inform ED of the purpose of today's visit.
On today's visit LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also requested copies of facility and resident records. During the course of the investigation the following was revealed. LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed copies of facility and resident records. The records reviewed included email communication between the facility and the Reporting Party (RP), Resident Preplacement Appraisal Information, Physician's Report, Resident (R) #1's Veterans Administration (VA) Long Beach medical records , California Assisted Living Waiver (ALW) Program Individual Service Plan (ISP). Admission Agreement, ECHO Hospice of Orange County records, Mainplace Senior Living
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
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 6
Control Number 22-AS-20230317144713
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: 06/10/2023
NARRATIVE
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photos of R1 and R1's room, Housekeeping Room Checklist, Incident Report for R1, and a blank Controlled Drug Record. Regarding the allegation: Facility failed to provide a clean and sanitary environment, LPA Velazquez conducted interviews with residents and staff. 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. LPA Velazquez reviewed photos of R1's room that revealed feces on the toilet seat in R1's bathroom and another picture with a soiled diaper and soiled toilet paper on the floor of R1's bathroom. 2 of 6 individuals interviewed stated that some staff will leave soiled diapers in resident rooms for housekeeping to throw out the following day. Regarding the allegation: Resident's call button is inoperable, 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. At 11:45 AM during today's visit LPA Velazquez along with a Medication Technician (MT) toured the facility and tested several pull cords in resident rooms. Per the MT when a pull cord is activated it will light up on a large screen at the Health Services desk as well as staff cellphones or facility phones that the use the CISCOR application. When LPA and MT entered room 334 where there were 2 resident beds, they observed the pull cord system did not function properly which MT confirmed. A second MT came to test the pull cords in room 334 and also observed they were not functioning properly. One of the residents also did not have a pull cord at their bedside. Regarding the allegation: Facility is not following reporting requirements, LPA Velazquez reviewed and Incident Report for R1 for an incident dated November 8, 2022 that documented the submission date as November 22, 2022 which is late pursuant to regulation. The Incident Report also failed to document that R1's physician and R1's responsible party were notified of this incident. Executive Director Rhon Hipolito confirmed R1's physician and responsible party were not notified of R1's incident that occurred on November 8, 2022. Regarding the allegation: Facility does not answer phone calls, upon arrival at the facility today, LPA Velazquez observed signage documenting visiting hours from 8 AM - 8 PM at the main entrance of the facility which was locked. LPA Velazquez observed no staff present at the reception desk. At 8:30 AM LPA Velazquez proceeded to call the facility and left a voicemail message because no one answered the phone.

Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility failed to provide a clean and sanitary environment, Resident's call button is inoperable, Facility is not following reporting requirements, and Facility does not answer phone calls are all deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is/are being cited on the attached LIC 9099D. An exit interview with Medication Technician Anthony Sanchez and a copy of this report along with the appeal rights, LIC 811, and LIC 9098 were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20230317144713
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: 06/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2023
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. This requirement is not met as evidenced by: based on record review and interview the Licensee did not ensure
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Licensee to ensure the facility is clean, safe, sanitary and in good repair at all times. Licensee to submit written statement to LPA indicating how exactly they intend to adhere to this regulation by POC due date.
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the facility was kept clean and sanitary as documented in the narrative of this report. This poses a potential risk to the health and safety of residents in care.
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Type B
06/16/2023
Section Cited
CCR
87303(i)(1)(A)
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Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria...Operate from each resident's living unit. This requirement is not met as
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Licensee to ensure the pull cord signal system is operating at all times and submit written proof to LPA by POC due date.
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evidenced by: based on observation and interview the Licensee did not ensure the pull cord system was operable in room 334. This poses a potential risk to the health and safety of residents in care.
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14
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: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20230317144713
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: 06/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2023
Section Cited
CCR
87211(a)(1)(A-D)
1
2
3
4
5
6
7
Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require...the following: A written report shall be submitted to the licensing agency and to the person responsible for
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Licensee to ensure it submits timely incident reports pursuant to regulation.
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the resident within seven days of the occurrence...events specified in (A) through (D) below. This requirement is not met as evidenced by: based on interview & record review the licensee did not notify R1's RP of the incident. This poses a potential risk to the health & safety of residents in care.
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9
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Licensee to submit written statement to LPA indicating how exactly they intend to adhere to this regulation by POC due date.
Type B
06/16/2023
Section Cited
CCR
87468.1(a)(9)
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7
Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have communications to the licensee from their representatives
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Licensee to submit written statement to LPA indicating how exactly they intend to adhere to this regulation by POC due date.
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answered promptly and appropriately. This requirement is not met as evidenced by: based on observation & interview the licensee did not ensure the facility phone is answered promptly. This poses a potential risk to the health & safety of residents in care.
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9
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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: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20230317144713
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: 06/10/2023
NARRATIVE
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photos of R1 and R1's room, Housekeeping Room Checklist, Incident Report for R1, and a blank Controlled Drug Record. Regarding the allegation: Facility failed to administer medication, LPA Velazquez reviewed R1's MAR for the months of January 2023 and February 2023. The facility also utilizes a Controlled Drug Record where medications such as PRN Morphine and Ativan are documented and signed by the staff assisting the resident with the self-administration of Morphine and Ativan. Per a Medication Technician, Morphine tablets are administered by facility staff with liquid Morphine administered by Hospice agency licensed health professionals only. The facility could not provide a copy of R1's Controlled Drug Record or their PRN Medication Administration Records. 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. 2 of 6 individuals interviewed stated they administered controlled drugs Ativan and Morphine to R1 and documented it on the Controlled Drug Record with their signatures as required by the facility. Regarding the allegation: Facility failed to provide resident's record to emergency personnel, 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. 2 of 6 individuals interviewed stated it is the facility's policy to immediately give emergency personnel resident documents such as the resident's Face Sheet and Medication List anytime a resident goes out to the hospital. Regarding the allegation: Facility failed to provide care and supervision to resident, 13 of 13 individuals interviewed provided conflicting statements and could not corroborate the allegation. 7 of 7 individuals interviewed indicated they felt the facility provided adequate care and supervision to residents in care.

Based on the observations made by LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Facility failed to administer medication, Facility failed to provide resident's record to emergency personnel, and Facility failed to provide care and supervision to resident are deemed UNSUBSTANTIATED. An exit interview was conducted with Medication Technician Anthony Sanchez and a copy of this report along with the appeal rights, LIC 811, and LIC 9098 were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6