306005636-11-15-2023-22-AS-AORZ-CY2QST-20231129112603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:26:36 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
06/29/2022 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220629113139

FACILITY NAME:	MAINPLACE SENIOR LIVING		FACILITY NUMBER:	306005636
ADMINISTRATOR:	PHAT T. NGUYEN		FACILITY TYPE:	740
ADDRESS:	1800 1832 W. CULVER AVENUE		TELEPHONE:	(714) 978-2534
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	153	CENSUS: 105	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Rhon Hipolito		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained injuries from a fall while in care.

Resident has fallen multiple times while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez, regarding the allegations mentioned above. LPA met with Administrator (AD) Rhon Hipolito and explained the purpose of the visit.

Interviews were conducted with two staff and Resident 1 (R1). Two out of two staff corroborated both allegations, and stated they did not recall the exact dates and times but stated R1 fell numerous times and at least one of those times required hospitalization. Per both staff, a re-appraisal of R1 due to falls was not done to their knowledge. R1 also corroborated both allegations and stated they fell multiple times, but did not recall exact dates and times. R1 stated that as a result of these falls they are no longer ambulatory.

LPA reviewed facility progress notes for R1, which stated R1 sustained a fall on 6/10/22 at 6:30 a.m., 6/19/22 at 10:00 a.m., 6/20/22 at 12:10 p.m., 6/23/22 at 4:30 p.m., and on 6/28/22 R1 was sent to the hospital for another fall. (Cont. LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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 3

Control Number 22-AS-20220629113139

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: 11/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Appraisal for R1 dated 4/14/2022, states R1 is alert, oriented, with no impairment, and able to walk without any physical assistance. After sustaining falls in June of 2022, R1’s appraisal was not updated and R1 was not re-assessed. On 7/06/22, R1 returned from the hospital under Haven Hospice with a diagnosis of brain hemorrhage. Per disclosures made during interviews, and records obtained, LPA determined resident had fallen multiple times and sustained injuries from a fall while in care. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 22-AS-20220629113139

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: 11/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/16/2023 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	...appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.. reappraisals shall document changes in the resident's physical, medical, mental, and social condition... This requirement is not met as evidence by;	1 2 3 4 5 6 7	AD stated a monthy in-service is held regarding any changes in condition for residents and procedures have now been implemented for a new care plan to be assessed once this is a change in condition. AD will provide LPA with proof of in-service held and new care plan assessments via email
	8 9 10 11 12 13 14	R1 sustained a fall on 6/10/23 at 6:30 a.m., 6/19/22 at 10:00 a.m., 6/20/22 at 12:10 p.m., 6/23/22 at 4:30 p.m., and on 6/28/22. R1 was not re-assesed and appraisal was not updated to reflect resident's change in condition, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	by POC date.
Type A 12/15/2023 Section Cited CCR 87463(c)	1 2 3 4 5 6 7	...licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement is not met as evidence by:	1 2 3 4 5 6 7	AD stated Health Care Coordinator arranges meetings for residents, RPs, and facility staff to discuss significant changes in residents' condition and will continue to implent this procedural policy. AD will provide LPA with proof of meetings being held via email by POC date.
	8 9 10 11 12 13 14	R1 sustained a fall on 6/28/22 that required hospitalization, resulting in a significant change in R1's condition. A meeting was not arranged with R1, RP, or facility staff in regards to change of condition, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3