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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:33:59 PM

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
08/02/2022 and conducted by Evaluator Claudia Gutierrez
COMPLAINT CONTROL NUMBER: 22-AS-20220802095010
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: 79DATE:
10/26/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rhon HipolitoTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Resident's call button is in disrepair.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Administrator In Training (AIT) Rhon Hipolito and Wellness Director (WD) Kim Mims. LPA was taken on a guided tour of the inside and outside of the facility.

Complaint alleges resident's call button is in disrepair. Interviews were conducted with former Executive Director (ED) Phat Nguyen, staff, and Reporting Party (RP).

During interviews, RP stated the facility had no call button, just reception bells. ED Nguyen stated the call buttons are on a “piggyback system” and that a resident ripped theirs out of the wall, “so it took down the whole system.” In the meantime, the facility had given the residents silver desk bells. Staff 1 (S1), during their interview, stated that the light to room 326 was broken and could not be turned off. Therefore, staff "ignore" the light. (Cont. LIC 9099-C).
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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 3
Control Number 22-AS-20220802095010
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: 10/26/2022
NARRATIVE
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During today’s visit, LPA observed different call lights on while on a guided tour in the hallway of the facility. An interview with S1 confirmed the call button lights continue to be inoperable. Per disclosures made during interviews, and observations made by LPA it was determined that resident's call button is in disrepair; the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated California Code of Regulations, Title 22, 87303(a).

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220802095010
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: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents.
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Administator In Training (AIT) Rhon Hipolito stated the facility call button system is set to be repaired from 11/28/22-12/02/22. AIT will provide LPA with documentation related to repairs via email by 11/28/22 and inform LPA throughout the course of repairs.
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This requirement is not met as evidence by; the facility's entire call button system is inoperable, which poses a potential health and safety 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3