306005636-4-23-2024-22-AS-AORZ-D4SUXR-20240429155847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:14:43 PM

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
04/15/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240415111317

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: 106	DATE:	04/23/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Rhon Hipolito		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's belongings
Facility staff are not answering communications from resident's responsible person

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and witness as well as reviewed and obtained pertinent documentation such as skilled nursing discharge paperwork and inventory list. Regarding the allegations that facility staff did not safeguard resident's belongings and facility staff are not answering communications from resident's responsible person, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 02/22/2024 after hospitalization at a skilled nursing facility (SNF). Discharge paperwork indicated resident's needs included a wheelchair but inventory list at discharge stated resident had no belongings. Staff 1 (S1) stated assisting the resident out of bed at the SNF and assisting the resident into van. The SNF took the wheelchair back the resident was in and resident boarded the van. Three out of three staff indicate resident did not have a wheelchair when the resident arrived to the facility and facility's wheelchair was used by the resident. CONTINUED ON LIC 9099C DATED 04/23/2024

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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-20240415111317

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: 04/23/2024

NARRATIVE

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S1 states resident did not have shoes on when the staff picked up the resident and states the resident had on grippy socks only. Two out of two staff deny seeing the resident with shoes. Facility progress notes dated 02/23/2024 indicated 911 was called twice for resident with resident being sent out to the hospital in the early morning hours. Facility documentation shows facility left a message for the resident's family on two different occasions that night. Staff 2 states having a conversation with family on the telephone and in-person regarding the alleged missing wheelchair and shoes. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, all allegations are deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC9099 (FAS) - (06/04)

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