306005636-6-12-2023-22-AS-AORZ-CZUNUT-20240126094649

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 06/12/2023
Date Signed: 06/12/2023 06:53:05 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
01/20/2023 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230120095133

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: 102	DATE:	06/12/2023
		UNANNOUNCED	TIME BEGAN:	02:03 PM
MET WITH:	Business Office Coordinator Chasidy Washington		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

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Illegal eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to follow up on Complaint investigation. During visit LPA met with Business Office Coordinator Chasidy Washington and Coordinator Elizabeth Mendoza. Ombudsman Joan Matheson was present and Administrator Rohn Hipolito was present via telephone.
During investigation LPA toured facility, conducted interviews, and requested pertinent documents such as warning notice, copy of eviction notice and resident file.
Regarding allegation Illegal Eviction, investigation revealed the following, Resident 1 and Resident 2 were issued final notice warnings dated 2/3/23 regarding disruptive verbal altercations with each other.Both parties were warned that further inappropriate behavior could lead to a 30 Day eviction notice. On 4/4/23, Resident 1 was issued a 30 day eviction notice for failure to follow house rules. Licensing Department granted approval for eviction notice. At this time facility has received court approval for Unlawful detainer but has not issued to Resident 1 as of yet. Resident 2 went to hospital back in February 7, 2023. Hospital contacted and notified facility that resident has a change in level of care on 2/7/23. On February Facility director conducted a reappraisal of R2. Based on information gathered from investigation CONT. 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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-20230120095133

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAINPLACE SENIOR LIVING	FACILITY NUMBER: 306005636
	VISIT DATE: 06/12/2023

NARRATIVE

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Facility failed to provide proper 30 day eviction procedures and did not include the necessary information and does not meet the requirements per Title 22 regulations. The preponderance of evidence standard has been met, therefore the allegation illegal eviction are deemed SUBSTANTIATED. California Code of Regulations Title 22 Division 6 chapter 8 is being cited on attached LIC 9099D.

An exit interview was conducted and copy of Appeals rights and confidential names list was left at facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230120095133

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAINPLACE SENIOR LIVING	FACILITY NUMBER: 306005636
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/13/2023 Section Cited CCR 87224(c)	1 2 3 4 5 6 7	eviction procedures.(c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.	1 2 3 4 5 6 7	Licensee to review the regulatory requirements for eviction procedures and provide an in-service training to all staff regarding the adequate procedure required prior to conducting a client's eviction. Licensee to provided proof of training.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility did not comply with proper eviction procedures which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

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