306005636-9-26-2025-22-AS-AORZ-DM4TAJ-20251003143335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 09/26/2025
Date Signed: 09/26/2025 03:35:12 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
04/18/2024 and conducted by Evaluator Hanna Gough

COMPLAINT CONTROL NUMBER: 22-AS-20240418131913

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:	09/26/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Rhon Hipolito		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Lack of care and supervision resulted in resident sustaining a fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) Rhon Hipolito and discussed the purpose of the visit.

The investigation into the allegation of Lack of care and supervision resulted in resident sustaining a fracture revealed the following: On April 13, 2024, at approximately 6:30PM Resident #1 (R1) had an unwitnessed fall in the Memory Care unit resulting in the need of a hip replacement. R1 was admitted to the facility on December 14, 2022. Per physician report on file, R1 had no motor impairment, was non-ambulatory due to their mental condition only and was able to independently transfer. The physicians report stated that R1 was diagnosed with Dementia and that R1 is checked as yes for confused/disoriented. The physician report was not dated; however, was signed by a physician.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

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-20240418131913

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: 09/26/2025

NARRATIVE

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Facility pre-placement appraisal for R1 dated December 6, 2022, documented that R1 ambulated independently, can walk without physical assistance, are active with no physical assistance required and are able to go up and down stairs easily. R1s appraisal also stated that R1 did not need help with moving about the facility. The appraisal was signed by R1s authorized representative on December 6, 2022. LPA observed R1s service plan with an initiation date of December 28, 2022, stating that R1s mobility is marked as assistance as needed, ambulates independently, transfers independently and is ambulatory. The service plan also states that R1 is occasionally forgetful with reminders. Progress notes done by facility staff covered the dates of March 4, 2024, to April 4, 2024. The progress notes stated that there have been no changes to R1s activities of daily living or care needs in the past month. LPA observed an incident report dated April 18, 2024, stating that staff was inside the memory care dining room when they heard R1 scream. Staff immediately checked on R1 and observed a bump on R1s forehead and R1 complained of pain on their right arm. R1 stated they lost balance and fell due to someone bumping into them. The incident report stated that paramedics were called and R1 was transported to the hospital for further medical assessment and treatment.

During interviews it was revealed that six of six staff stating R1 was independently ambulatory and was able to move around the facility with no assistance. Six of six staff stated that R1 did not use assisted devices when walking, such as a cane or walker. Three of six staff stated that R1 did not have a history of falls. Three of six staff stated that the memory care unit always has staff in one of the common areas of the unit. It was reported to two of six staff that on April 13, 2024, via phone call that R1 fell in the tv room outside of the dining room as the incident occurred over the weekend on their days off. It was reported to two of six staff that the closest staff was in the dining room overseeing dinner service next to the tv room when the incident occurred. It was reported to staff #1 (S1) that the resident had left the dining room during dinner service and was seen walking towards the tv room before the incident occurred. Two of six staff informed LPA that facility staff called 911 and R1 was sent to the hospital for further evaluation due to R1 hitting their head. R1 was admitted to the hospital and was diagnosed with a hip fracture. LPA attempted to contact R1s responsible party but was unsuccessful.

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SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240418131913

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: 09/26/2025

NARRATIVE

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Although R1 sustained a fall at the facility, it remains unclear if the fall occurred due to a lack of care and supervision. Based on information gathered during the investigation the department is unable to ascertain if the above 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 Rhon Hipolito And a copy of this report was provided at the time of the investigation.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

LIC9099 (FAS) - (06/04)

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