306005636-1-31-2024-22-AS-AJLO-D2VT5R-20240228132558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:10:53 PM

Substantiated

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
08/09/2022 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220809112719

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: 108	DATE:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Business Office Manager, Chasidy Washington		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not adequately supervise resident in care resulting in multiple wanderings from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Complaint Investigation for the purpose of delivering findings regarding the allegation mentioned above. LPA met with Business Office Manager, Chasidy Washington and Community Liason, Elizabeth Mendoza.

On 8/10/22, the Department received an Unusual Incident Report (LIC624) stating that on 8/09/22 at approximately 3:25 p.m. staff noted Resident 1 (R1) missing. Staff notified Wellness Director (WD) Kimberly Mims and Executive Director (ED) Phat Nguyen. A search of the unit including bathroom areas, bedrooms, and closets was conducted. Window in resident room 306 identified as possible exit point. Search of facility and surrounding area was initiated and expanded to surrounding neighborhoods. Per Case Management visit dated 8/10/22, R1 was found on 8/10/22 at approximately 1:15 p.m. by a good Samaritan standing outside a home miles away from the facility. Per Physician Reported dated 7/29/2022, R1 is not able to leave facility unassisted and needs special observation and night supervision due to confusion and forgetfulness.
(Cont. LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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-20220809112719

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: 01/31/2024

NARRATIVE

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On 8/04/22 the Department had previously received an Unusual Incident Report (LIC24) regarding R1 stating that on 8/03/22, staff had noticed that R1 was not in the common area and immediately began looking for them. At the same time R1’s family drove into the facility parking lot and saw R1 coming around the corner of the building and began walking down the street. R1’s family member got out of the car and followed R1. The family member and facility staff were able to assist R1 return to the facility.

Based on the facility’s own disclosure of events, LPA determined that Staff did not adequately supervise resident in care resulting in multiple wanderings from the facility. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. A deficiency is being cited per Title 22 Division 6 of the California Code of regulations. (See LIC9099-D).

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220809112719

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/01/2024 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	“Care and supervision” means the facility assumes responsibility for, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Community Liason stated auditory alarms on windows are maintained in operable condition and staff training has been conducted to address auditory alarms immediately after being activated, and training regarding resident wandering behavior. Additional activites are also being provided to deter
	8 9 10 11 12 13 14	Based on the facility’s own disclosure of events, they did not assume responsibility for Resident’s wandering behavior, resulting in multiple wanderings from the facility, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	wandering behavior. Community Liason will provide LPA with proof of training conducted regarding resident wandering behavior and elopement and activity calendar by POC date.
	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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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