306005636-4-10-2024-22-AS-LMOA-D5SNTT-20240531104509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 04/10/2024
Date Signed: 04/10/2024 02:43:18 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
01/12/2024 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240112162107

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: 110	DATE:	04/10/2024
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Rhon Hipolito - Executive Director		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Facility did not safeguard residents’ belongings in room.
Facility did not report theft.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to complete additional interviews and deliver the findings on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit.

The complaint investigation consisted of interviews with facility staff, residents, a resident family member, a witness, and document review. Two additional witnesses were contacted but could not be reached.

Regarding the complaint allegation: Facility did not safeguard residents’ belongings in room.

During the investigation interviews were conducted with facility staff, residents, and witnesses for a total of nine interviews.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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-20240112162107

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: 04/10/2024

NARRATIVE

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Two additional interviews were attempted, but witnesses could not be reached. Regarding the allegation above, 8 of 9 individuals were unable to corroborate the complaint allegation. Three of four residents interviewed denied any problems with anyone entering their room unauthorized and all residents reported they fell safe in the community. Resident 2 (R2) denied any personal items being stolen and said staff only enter the room to pick up dirty laundry. Resident 4 (R4) denied anyone entering the room unauthorized, and denied anything being stolen from the room. When asked if anything has been stolen, R4 said, “Thank God… nothing valuable here.” R3 denied anything has been stolen form as well. All staff interviewed denied items being stolen form residents, but all did mention that some residents claim things have been stolen form them. Staff 1 (S1) mentioned a resident who claimed items were stolen from them and then a couple days later claimed whoever stole the items, brought them back. Staff 3 (S3) mentioned the same resident, and claimed the resident has reported items are missing and really the items are misplaced by the resident. S3 said once after the resident claimed items were missing, S3 located the missing item in the resident’s room.

Regarding the complaint allegation: Facility did not report theft

During the interviews it was discovered the Resident 1 (R1) reported medications were stolen from the resident’s room. Document review revealed the resident’s son was informed of the reported theft and was informed R1 contacted the Police. The incident number and detective's name in the facility progress notes matched the incident report number and detective’s name provided by R1. During interviews with Staff 2 (S2) and Staff 3 (S3) both were unaware of any reported theft from R1 being reported to the facility.

Based on the information gathered during the investigation through interviews, document review, and observations, 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: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

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