306005636-11-20-2023-22-AS-AORZ-CZUNUS-20240126094648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:03:34 PM

Unfounded

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
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: 106	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Administrator, Rhon Hipolito		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not provide medications to resident as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst’s (LPA’s) Jenifer Tirre and Rosie Quiroz made an unannounced joint visit to conduct follow up into complaint Investigation. LPA's was greeted and granted entry by staff. LPA's identified themselves and discussed the purpose of the visit with Executive Director Rhonwinn Hipolito.

During the visit, LPA Tirre conducted interviews and requested pertinent documents such as Physician’s Report and Personnel Report. During the investigation, Interviews were conducted with staff and residents, Pertinent documents were reviewed and requested. On 1/20/23 the department received allegations that facility staff did not provide medications to resident as prescribed. Per interviews conducted with staff five out of five staff confirmed there was no issues with prescribed medications provided to residents. Interviews with residents confirm that five out of five residents had no issues with receiving medications and that prescribed medications were administered. Interviews with four of five staff also confirmed that Resident 1 managed their own medications. Resident Physcian's Report dated 6/28/22 confirms resident 1 is able to administer own CONTINUED ON 9099 C

Unfounded

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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAINPLACE SENIOR LIVING	FACILITY NUMBER: 306005636
	VISIT DATE: 11/20/2023

NARRATIVE

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prescription medications, able to administer own PRN medications and able to store own medications.

Based off interviews conducted and documents received Resident 1 was able to self administer medications at time initial complaint received therefore the above allegation Staff did not provide medications to resident as prescribed is deemed UNFOUNDED meaning , that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies cited during today's visit.

An exit interview was conducted with (ED) Hipolito and a copy of today's report and LIC 811- Confidential Names were provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
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: 106	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Administrator, Rhon Hipolito		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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9

Staff spoke to resident in an inappropriate manner.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst’s (LPA’s) Jenifer Tirre and Rosie Quiroz made an unannounced joint visit to conduct follow up into complaint Investigation. LPA's was greeted and granted entry by staff. LPA's identified themselves and discussed the purpose of the visit with Executive Director Rhonwinn Hipolito.

During the visit, LPA Tirre conducted interviews and requested pertinent documents such as Physician’s Report and Personnel Report. During the investigation, Interviews were conducted with staff and residents, Pertinent documents were reviewed and requested. On 1/20/23 the department received allegations that facility Staff spoke to resident in an inappropriate manner. Based on interviews conducted four of five staff state they are unaware of staff speaking inappropriately to residents. One staff confirmed they have witnessed staff acting rudely towards residents. Interviews with residents confirmed that five of five residents stated they have no issues with staff.Based off interviews and observations the allegation staff spoke to resident in an inappropriate manner is deemed UNSUBSTANTIATED. Although the allegations may have happened or is valid there is no preponderance of evidence to prove the alleged violations did or did not occur.
An exit interview was conducted with Administrator and a copy of report was provided to facility

Unsubstantiated

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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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 3