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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005636
Report Date: 03/14/2024
Date Signed: 03/14/2024 12:07:12 PM


Document Has Been Signed on 03/14/2024 12:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
306005636
ADMINISTRATOR:RHONWINN HIPOLITOFACILITY TYPE:
740
ADDRESS:1800 1832 W. CULVER AVENUETELEPHONE:
(714) 978-2534
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:153CENSUS: 112DATE:
03/14/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Brianna Garcia-Business Office ManagerTIME COMPLETED:
12:22 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Plan of Correction (POC) visit in conjunction with complaint control #22-AS-20230629084645 and citation issued on 01/10/2024. LPA was greeted and granted entry into the facility by Business Office Manager (BOM) Brianna Garcia and explained the reason for the visit.

On 01/31/2024, Licensee failed to correct the following:
Deficiency cited under Title 22 Regulation 87412 (c)(1)(A)(B) pertaining to Personnel Records (Training and Orientation...in-service training).

Deficiency cited under Title 22 Regulation 87412 (c)(1)(A)(B) pertaining to Personnel Records (Training and Orientation...in-service training) has NOT been cleared.

Per California Code of Regulation under 87707 (a)(2) under Training Requirements If Advertising Dementia: Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with BOM Garcia and a copy of this report along with the LIC809D and Appeal Rights were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/14/2024 12:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
87412(c)(1)(A)(B)

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Personnel Records (1) training and orientation shall be documented: (A)...at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B)For staff who provide direct care to residents with dementia...the licensee shall document
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Licensee to provide up to date trainings transcripts for S1, S2 and S3 by POC due date.
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...orientation received as specified in Section 87707(a)(1)...in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidence by: Based on LPA's observations and file reviews S1, S2 and S3 do not meet Tittle 22 training requirements.
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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: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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