306005636-1-5-2024-22-AS-SSAS-D2PMPZ-20240222084757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 01/04/2024
Date Signed: 01/05/2024 10:17:49 AM

Unsubstantiated

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
12/26/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231226144300

FACILITY NAME:	MAINPLACE SENIOR LIVING		FACILITY NUMBER:	306005636
ADMINISTRATOR:	RHONWINN HIPOLITO		FACILITY TYPE:	740
ADDRESS:	1800 1832 W. CULVER AVENUE		TELEPHONE:	(714) 978-2534
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	153	CENSUS: 109	DATE:	01/04/2024
		UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Executive Director-Rhon Hipolito		TIME COMPLETED:	12:17 PM

ALLEGATION(S):

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Staff are not addressing resident's fall risk.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by executive director (ED) Rhon Hipolito.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged that staff are not addressing resident's fall risk. LPA De Perio conducted 7 resident interviews, of which 7 out of the 7 interviews did not corroborate with the allegation. LPA De Perio conducted a total of 2 staff interviews, of which also did not corroborate with the allegation by stating that staff are trained on the protocol for when a resident falls and is also advised to contact medical assistance immediately for the resident to obtain an evaluation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20231226144300

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: 01/04/2024

NARRATIVE

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Per documentation review, resident (R1) is diagnosed with Dementia and has a history of falls. On December 25, 2023, R1 sustained an unwitnessed fall in the facility common area, and staff contacted 911, to which then R1 was transported to the hospital. LPA De Perio conducted an interview with R1's responsible party (RP) and confirmed that the facility notified RP immediately of the incident. RP also verified that R1 has had a history of falls, but stated that the fall sustained at the facility is not due to staff neglect, but because R1 likes to walk around and would take off their eyeglasses. R1 is also ambulatory and receives assistance with dressing and bathing.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with ED Hipolito. A copy of this report was provided and explained.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC9099 (FAS) - (06/04)

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