306005636-7-23-2024-22-AS-MSTC-D7Q2FE-20240731172124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:51:49 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
07/18/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240718134344

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: 114	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Briana Flores		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident did not receive medication correspondence sent to the facility in a timely manner

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Rhonwinn Hipolito was present and able to assist later during the visit.

LPA requested and obtained the current facility census. An interview was conducted with Wellness Director Ruby Raccamagao. Resident records for five individual currently in care at the facility were requested, obtained and reviewed during the visit. Front desk staff present was also interviewed. Four resident interviews were attempted or conducted during the visit. LPA additionally reviewed and obtained copies of the facility's grievance log and package delivery log.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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-20240718134344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MAINPLACE SENIOR LIVING	FACILITY NUMBER: 306005636
	VISIT DATE: 07/23/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099

Regarding the allegation that Resident did not receive medication correspondence sent to the facility in a timely manner, the following has been concluded: Based on records reviewed, residents R1, R2, R3 and R4 have been confirmed to have been assessed to be capable of managing their own medication by their respective primary care physicians. During interviews conducted, one out of four residents indicated that their medication was delivered directly to their unit by the pharmacy upon request from their physician. Another one of four residents stated that she had medication delivered by postal service on or around July 10, 2024 but never received it. The same resident stated that facility management had reported that no postal deliveries had been documented by front desk staff on that day. Another package was noted to have been brought by USPS on July 7, 2024 and stated by staff to have been brought to the resident's unit as the resident does not come down to the lobby. No active grievances regarding interference with personal correspondence appear to have been formally filed with facility management in the period from January 23, 2024 to the present visit.

Based on the information gathered during the investigation through interviews and document review, 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 to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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