306005636-5-8-2024-22-AS-LMOA-D7Q4QR-20240731191844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:33:33 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
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:	12:00 PM
MET WITH:	Ruby Raccamagao		TIME COMPLETED:	12:29 PM

ALLEGATION(S):

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9

Resident sustained multiple falls while in care.

INVESTIGATION FINDINGS:

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2
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5
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Regarding the complaint allegation: Resident sustained multiple falls while in care.

7 of 7 individuals either denied the allegation or were unable to support the allegation. During an interview, Resident 1 (R1) admitted to falling about once every two months and the resident claims to use a walker which was present during the interview. Staff 1 (S1) denied R1 is a fall risk and claims R1 walks to the dining room to eat. Staff 5 (S5) stated R1 has had falls in the past but has improved recently.
Based on the information gathered during the investigation through interviews, document review, and observations, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated.

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

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: 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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