306005636-5-8-2024-22-AS-LMOA-D7Q4QQ-20240731191844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:32:07 PM

Substantiated

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
02/08/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230208162544

FACILITY NAME:	MAINPLACE SENIOR LIVING		FACILITY NUMBER:	306005636
ADMINISTRATOR:	PHAT T. NGUYEN		FACILITY TYPE:	740
ADDRESS:	1800 1832 W. CULVER AVENUE		TELEPHONE:	(714) 978-2534
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	153	CENSUS: 111	DATE:	05/08/2024
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Ruby Raccamagao		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Resident in care sustained multiple bruises.
Residents in care engage in unsafe interactions

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 and residents, and included document and photo review. A total of 7 interviews were conducted.

Regarding the complaint allegation: Resident in care sustained multiple bruises.
3 of 7 individuals confirmed the allegation above. During interviews and document review, it was discovered Resident 1 (R1) sustained bruises to different areas of the upper body. According to Staff 1 (S1) after a February 7, 2023 incident, when staff went to assess R1, bruising was noted on R1 and the bruises did not look like they were from a fall. Staff 2 (S2) responded to the incident on February 7, 2023 and went to R1’s room to assist the resident and observed bruising to R1 and stated, bruising was all over R1’s body including the nose.”
Continued on LIC9099C

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230208162544

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: 05/08/2024

NARRATIVE

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Regarding the complaint allegation: Residents in care engage in unsafe interactions.

7 of 7 individuals confirmed the allegation above. During interviews, Staff 1 (S1) revealed Resident 2 (R2) was given an eviction notice for yelling behavior and making the community unsafe. According to S1, facility staff reached out to the family of R1 regarding the concerning behavior of R2. Staff 3 (S3) mentioned that other residents always report to staff that R2 is always yelling. Staff 2 (S2) stated, we (staff) thought it was all verbal, R2’s always yelling and screaming. Staff 5 (S5) stated, other residents would tell staff that R2 yells at R1 and calls R1 names. During an interview, R2 admitted to biting R1 on the fingers so R1 would let the resident go. According to R2, R1 was holding on to R2 after slipping and falling of the potty.

Based on the evidence gathered through interviews and document review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6.

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

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230208162544

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
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 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Wellness Director agrees to conduct an in-service training for all staff on Personal Rights of residents in all facilities. Wellness Director will email LPA Haley an outline of the topics covered in the in-service training and a copy of the sign in sheet of the staff in attendance by the POC due date: Wednesday, May 15, 2024 at 1PM.
	8 9 10 11 12 13 14	The above requirement is not being met as evidenced by interview confirmation, document, and photo review that revealed Resident 1 (R1) sustained multiple bruises to upper body while in care. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/15/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Wellness Director agrees to conduct an in-service training for all staff on Personal Rights of residents in all facilities, and a detailed plan that outlines what steps will be taken when residents engage in abusive behavior towards each other. Wellness Director will email LPA Haley an outline of the topics covered in the in-service training, a copy of the sign in sheet of the staff in attendance, and the detailed plan regarding resident on resident abuse by the POC due date: Wednesday, May 15, 2024 at 1PM.
	8 9 10 11 12 13 14	The above requirement is not being met as evidenced by interview confirmation and document review that reveal Resident 1 (R1) was being abused by Resident 2 (R2) while in care. This poses a health and safety risk to resident in care.	8 9 10 11 12 13 14

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 Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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