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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 01/10/2024
Date Signed: 01/10/2024 11:49:01 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
06/29/2023 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230629084645
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: 109DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Noemi Otero-Receptionist, Chasidy Washington-Business Office DirectorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Facility does not staff appropriately to meet residents' needs.
Residents are left unattended.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on 06/29/23. LPA was greeted and granted entry into the facility by Receptionist Noemi Otero. LPA explained the reason for the visit. Business Office Director Chasidy Washington arrived shortly after.

This agency has investigated the complaint alleging that facility does not staff appropriately to meet residents' needs. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Six of ten individuals interviewed denied the allegation. During the investigation LPA reviewed documents including the July, November and December 2023 staff schedule. On average there are four caregivers and two medication technicians for the morning shift, two to four caregivers and two medication technicians for the evening shift and two caregivers and one medication technician for the night shift. During interviews with the residents,
CONTINUED ON LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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 5
Control Number 22-AS-20230629084645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MAINPLACE SENIOR LIVING
FACILITY NUMBER: 306005636
VISIT DATE: 01/10/2024
NARRATIVE
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Resident 1 (R1) reported that the facility has enough staff and that staff do not take long to assist her.

Regarding the allegation that residents are left unattended, the investigation revealed the following: Nine of ten individuals interviewed denied the allegation. During interviews conducted with the residents, R2 reported that staff are good overall. Per R2 residents are not left unattended. During interviews conducted with staff, Staff 1 (S1) reported that she has not witnessed residents being left unattended and stated that caregivers always try their best.

Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED.

LPA Ramirez conducted an exit interview with Business Office Director Washington, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
06/29/2023 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230629084645

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: 109DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Noemi Otero-Receptionist, Chasidy Washington-Business Office DirectorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
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3
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9
Untrained staff providing care and supervision to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on 06/29/23. LPA was greeted and granted entry into the facility by Receptionist Noemi Otero. LPA explained the reason for the visit. Business Office Director Chasidy Washington arrived shortly after.

This agency has investigated the complaint alleging that untrained staff are providing care and supervision to residents. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Two of ten individuals interviewed confirmed the allegation. During interviews conducted with residents Resident 1 (R1) stated that staff do not have the required trainings to care for the residents. Records reviewed by LPA Ramirez included staff training transcripts for Staff 1 (S1), S2 and S3. Training transcript for S1 showed that S1 completed four hours of dementia care training on 11/28/23. S1 completed four hours of dementia training 13 months after their
CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20230629084645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MAINPLACE SENIOR LIVING
FACILITY NUMBER: 306005636
VISIT DATE: 01/10/2024
NARRATIVE
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date of employment. Training transcript for S2 shows Not Applicable (N/A) under Initial/Direct Care Staff Training dated 08/29/20. S2 date of employment is listed as 08/03/20. Training transcript for S3 does not show dementia care training. S3 date of employment is listed as 06/09/23.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: untrained staff are providing care and supervision to residents is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

A deficiency is being cited under Personnel Records 87412(c)(1)(A)(B)(1)(2).

An exit interview was conducted with Business Office Director Washington, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230629084645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAINPLACE SENIOR LIVING
FACILITY NUMBER: 306005636
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
87412(c)(1)(A)(B)
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Personnel Records (1) training and orientation shall be documented: (A)...at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B)For staff who provide direct care to residents with dementia...the licensee shall document
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Facility to provide up to date trainings transcripts for S1, S2 and S3 by POC due date.
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...orientation received as specified in Section 87707(a)(1)...in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidence by: Based on LPA's observations and file reviews S1, S2 and S3 do not meet Tittle 22 training requirements.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5