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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 02/14/2024
Date Signed: 02/14/2024 04:17:03 PM

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
11/20/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231120213146
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: 110DATE:
02/14/2024
UNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Rhonwinn Hipolito, administratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff did not ensure resident is administered eye drops as prescribed.
Staff did not ensure resident was provided a comfortable temperature.
Facility does not have adequate staffing to respond to resident's call in a timely manner.
Staff did not provide resident's authorized representative a copy of
admissions agreement.
Staff do not communicate with authorized representative changes of resident's health.
INVESTIGATION FINDINGS:
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13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after explaining the purpose of the visit. Facility administrator was present to assist with the visit.

The initial investigation visit was conducted at the facility on November 22, 2023. LPA requested and obtained partial resident records for resident R1, conducted a tour of the physical plant and interviewed multiple staff members.

A follow-up visit took place on February 2, 2024. One staff interview with the facility's Executive Director was conducted. Additional records requested and obtained. A tour of R1's former unit was also conducted. Additional witness interviews conducted in person or via telephone on February 9, 2024.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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
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
11/20/2023 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20231120213146

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: DATE:
02/14/2024
UNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Rhonwinn Hipolito, administratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not have adequate record keeping for resident.

Staff did not provide authorized representative with resident's records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after explaining the purpose of the visit. Facility administrator was present to assist with the visit.

The initial investigation visit was conducted at the facility on November 22, 2023. LPA requested and obtained partial resident records for resident R1, conducted a tour of the physical plant and interviewed multiple staff members.

A follow-up visit took place on February 2, 2024. One staff interview with the facility's Executive Director was conducted. Additional records requested and obtained. A tour of R1's former unit was also conducted. Additional witness interviews conducted in person or via telephone on February 9, 2024.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20231120213146
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: 02/14/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099-A
Regarding the allegation that Staff did not have adequate record keeping for resident, the following has been concluded: When a copy of the initial agreement concluded in November 2021 was requested by R1's authorized representative, no copy could be provided per a written staff statement indicaing the document had been misplaced. Following a change of ownership, an updated document was drafted and provided to the authorized representative. The statement corroborates that the facility had incomplete records for R1 that did not meet the requirements of Title 22 regulations.

Regarding the allegation that Staff did not provide authorized representative with resident's records, the following has been concluded: Based on email exchanges with the facility including timestamps, it was confirmed that the required maximum of two business days to obtain access to a resident's records upon request was not met after R1's authorized representative requested documents upon R1's discharge from the facility.

Two type B deficiencies were cited for failure to meet the requirements of the California Code of Regulations' Title 22 Division 6 on the attached form LIC9099-D.

An exit interview was provided and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20231120213146
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: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2024
Section Cited
CCR
87506(a)
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7
Per the California Code of Regulations: "A separate, complete, and current record shall be maintained for each resident in the facility"
This requirement was not met as evidenced by: Based on a review of written exchanges of facility staff with a resident's authorized representative, it was determined that at least
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3
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5
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7
Licensee will audit current records for accuracy and completeness and finish the process of updating admission agreements to the current ownership of the facility.
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9
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14
one resident's admission agreement had been misplaced, hence rendering the resident's records incomplete at the time. This constitutes a potential risk to the health, safety and welfare of residents in care.
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Type B
03/14/2024
Section Cited
CCR
87468.2(a)(19)
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Per CCR Section 87468.2(a)(19) on Additional Personal Rights of Residents in Privately Operated Facilities, residents shall (...)"have prompt access to review all of their records (...). (...) records shall be provided within two (2) business days (...)." This requirement was not met as evidenced by:
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7
Licensee will provide a statement indicating that all office staff have been informed of the regulatory requirement for providing records and will adhere to it for future requests.
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Based on records reviewed, facility records were not provided until more than two business days after a resident's authorized representative had requested them. This constitutes a potential risk to the health, safety and personal rights of 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20231120213146
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: 02/14/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff did not ensure resident is administered eye drops as prescribed, the following has been concluded: During an interview with R1, R1 stated she often did not receive her medication as prescribed. It is however unclear whether R1 has the ability to make accurate recollection due the primary diagnosis on file. Additional interviews were unable to corroborate that R1's condition had worsened due to a failure to receive treatment. A review of the facility's Medication Administration Records provided for the full period of admission did not evidence instances of missed administration.
Regarding the allegation that Staff did not ensure resident was provided a comfortable temperature, the following has been concluded: During a tour of the physical plant, the former resident's shared bedroom was measured to be at an adequate temperature and the thermostat as well as heating operations were shown to be operational.
Regarding the allegation that Facility does not have adequate staffing to respond to resident's call in a timely manner, the following has been concluded: An interview with R1 did not evidence issues with staff response time. The facility call system was witnessed to be operational during two tours of the physical plant. Additionally, staff posted schedules and clock punches were reviewed and did not evidence insufficient staffing levels.
Regarding the allegation that Staff did not provide resident's authorized representative a copy of
admissions agreement, the following has been concluded: When a copy of the initial agreement concluded in November 2021 was requested no copy could be provided per a written staff statement indicated the document had been misplaced. Following a change of ownership, an updated document was drafted and provided to the authorized representative.
Regarding the allegation that Staff do not communicate with authorized representative changes of resident's health, the following has been concluded: Based on a review of scheduling documents, staff notes and interviews, it was determined that facility staff reached out to R1's authorized representative after a change in behavior patterns and exit seeking became apparent and a recommendation of a placement in memory care was formulated.

Based on these conclusions gathered after review of records, site observation and staff, resident and witness interviews, the five allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5