306005636-4-16-2021-22-AS-SSAS-C36249-20210518170333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 04/16/2021
Date Signed: 04/16/2021 01:05:21 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
04/13/2020 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200413134942

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: CA	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 is not ensuring that resident has access to personal belongings
Facility staff failed to safeguard resident's personal belongings
Facility staff is not assisting resident has access to meals
Facility staff is not properly transporting resident
Facility staff failed to intervene in verbal altercations between residents
Facility staff threatened to evict resident
Facility is in disrepair

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 regarding allegations that R1’s personal belongings were not accessible and safeguarded, that staff were not providing R1 access to meals, not transporting R1 properly, threatening to evict R1 not providing intervention during verbal altercations of residents and not repairing facility. R1 was admitted into the facility on 9/28/19. Interviews were conducted with R1, staff and witnesses. Written statements by staff and facility records were also reviewed.

Allegation # 1- Facility staff is not ensuring that resident has access to personal belongings.

Based upon documentation and statements, R1 moved into the facility with a lot of belongings. R1 wanted all the belongings to be stored in his room. According to statements this filled the closet and reduced access to the closet.

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-20200413134942

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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On 10/21/19 staff moved R1 to a larger room. R1 did not like that room after a few days and asked to be moved back to the smaller room.

Allegation #2- Facility staff failed to safeguard resident’s belongings.

R1 notified staff on 4/11/20 of missing undergarments. R1 asked staff to assist in locating the garments. Staff could only locate 3 garments and offered to pay for more garments.

Allegation # 3- Facility staff is not assuring resident has access to meals.

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 his preference, order take out. According to interviews, R1 did not want certain staff to escort him to the dining room and if they showed up to his door he would refuse. R1 would also refuse if not taken to meals 10 minutes before meals were served.

Allegation #4- Facility staff are not properly transporting resident

R1 was assisted by staff to the dining room. Statements provided disclosed that sometimes R1’s walker would bump into doors or walls when entering rooms as R1 liked to walk through unassisted. On 2/27/20- R1 disclosed that staff let him run his hands into the door of his room. On 3/9/20 R1 hit the door with his elbow. No injuries were noted according to Progress notes.

Allegation #5- Facility staff failed to intervene in verbal altercation between residents

On 1/14/20, documents disclosed that R1 and R2 became involved in a verbal altercation. R1 began to yell at R2 and staff had to intervene. R2 was escorted out of the dining room and moved to a different table.

Allegation #6- Facility staff threatened to evict resident

Statements and progress notes were reviewed. Documents disclosed that when R1 would become upset and disrespect staff, they would ask R1 why he was still living at the facility if he was unhappy with the services provided.

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)

Page: 2 of 3

Control Number 22-AS-20200413134942

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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Allegation #7- Facility is in disrepair

Statements and progress notes were reviewed. According to progress notes, R1’s slider door was not locking correctly and R1’s key was getting stuck in the door lock. Facility maintenance fixed the door and the lock.

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.

An exit interview was conducted with Administrator Briana 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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