306005636-7-19-2022-22-AS-AORZ-CGWQZN-20220802123657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 07/13/2022
Date Signed: 07/19/2022 12:53:34 PM

Unfounded

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
06/15/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200615083228

FACILITY NAME:	MAINPLACE SENIOR LIVING		FACILITY NUMBER:	306005636
ADMINISTRATOR:	GOLLIHAR, JEFFERY		FACILITY TYPE:	740
ADDRESS:	1800 1832 W. CULVER AVENUE		TELEPHONE:	(714) 978-2534
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	153	CENSUS: 71	DATE:	07/13/2022
		UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Phat Nguyen, Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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-Responsible party did not get a copy of admission agreement.
-Responsible party did not receive a refund.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit. LPA Quiroz was COVID-19 screened and greeted by front desk receptionist. LPA Quiroz met with Administrator Phat Nguyen identified herself and discussed the purpose of today's visit to deliver findings for the complaint allegations listed above.
The initial 10-day tele visit was completed on 6/24/2020 via telephone due to COVID-19 precautionary measures. During the course of this investigation, LPA Quiroz conducted interviews, reviewed documents including but not limited Resident 1 (R1's) admission agreement, Resident Refund Request Summary dated 6/23/2020, Email from Administrator Jeff Gollihar dated 6/29/2020 at 9:51am and Main Place Senior Living Verification of Received/Reviewing Move-In Forms.
It was alleged that "Responsible Party did not get a copy of admission agreement " and "Responsible Party did not receive a refund." During the course of this investigation, LPA Quiroz conducted interviews with interviewees and reviewed documents listed above. 3 of 3 interviewees denied allegations.
CONTINUED ON NEXT PAGE...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022

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-20200615083228

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: 07/13/2022

NARRATIVE

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This agency has found the complaint allegations of "Responsible Party did not get a copy of admission agreement," and "Responsible Party did not received a refund " are deemed UNFOUNDED; Meaning that the allegations were false, could not have happened or are without a reasonable basis. We have therefore dismissed the complaint allegations listed above.

An exit interview was conducted with Administrator Phat Nguyen, and a copy of this report and LIC 811-Confidential Names were provided at exit.

On 7/19/2022, on or about 10:44am Administrator Phat Nguyen corrected visit date of inspection visit on 3 of 3 pages which were provided to Administrator Phat Nguyen at exit on visit conducted on 7/18/2022. Correction date was corrected from 7/13/2022 to 7/18/2022.

***This is an amended report***

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022

LIC9099 (FAS) - (06/04)

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