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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005636
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:35:38 PM


Document Has Been Signed on 05/08/2024 04:35 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
CCLD Regional Office, 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: 111DATE:
05/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ruby Raccamagao TIME COMPLETED:
01:14 PM
NARRATIVE
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During the investigation into complaint control number 22-AS-20230208162544 it was discovered the facility failed to report an attack that resulted in an injury to the Regional Office.

All serious incidents should be reported to the Regional Office within 7 days. Mainplace Senior Living failed to report a resident was attacked by another resident which resulted in injuries to the resident and the Orange County Sheriff being called.

LPA Haley received in-house notes that documented the incident and received details about the incident from Staff 1 (S1) during staff interviews.

As a result of today’s Case Management visit, a violation will be cited per California Code of Regulations Title 22.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/08/2024 04:35 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
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: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements
(a) Each licensee shall furnish...reports as the Department may require, including, but not limited to...
(1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified... below. This report shall include the resident’s name, age...disposition of the case.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Wellness Director agrees to conduct an in-service training for all staff on Reporting Requirements.
A sign in sheet and outline of the topics covered and duration of the in-service training will be emailed to LPA Haley by the POC due date.
Wellness Director agrees to send a detailed plan that outlines the steps that will be taken to ensure all serious incidents are reported. The detailed plan will include the following:
• Who will be responsible for sending incident reports
• A backup staff member responsible for reporting serious incidents.
The in-service training sign-in sheet, in-service training outline, and detailed plan on reporting serious incidents will be emailed to LPA Haley by Wednesday, May 15, 2024 at 1PM.
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This requirement is not being met as evidenced by the facilities failure to report the incident involving Resident 1 (R1) and Resident 2 (R2) which resulted in the police being called. This poses a potential health and safety risk to resident in care.
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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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2