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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005636
Report Date: 08/10/2022
Date Signed: 08/11/2022 08:40:26 AM


Document Has Been Signed on 08/11/2022 08:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 LIVINGFACILITY NUMBER:
306005636
ADMINISTRATOR:PHAT T. NGUYENFACILITY TYPE:
740
ADDRESS:1800 1832 W. CULVER AVENUETELEPHONE:
(714) 978-2534
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:153CENSUS: 75DATE:
08/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Phat Nguyen and Kimberly MimsTIME COMPLETED:
05:00 PM
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Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of Complaint #22-AS-20220103122410, #22-AS-20210102174521 and #22-AS-20210428152302. Upon arrival, LPA met with Wellness Director Kimberly Mims and explained the purpose of the visit. Ms. Mims informed LPA that she was just sending over an unusual incident report to the Department regarding a resident elopement. Operations Manager Phat Nguyen was out of the building and arrived a short time after LPA. A tour of the Memory Care unit was conducted.

Resident #1 moved into the facility on 7/27/22. R1 could not leave the facility unassisted and exhibited wandering behavior. On 8/9/22 at approximately 3:25pm, staff in Memory Care noted that Resident #1(R1) was missing. Staff notified Wellness Director Kimberly Mims and Operations Manager Phat Nguyen. A thorough search of the unit was conducted as well as the outside. The window in Room #306 was identified as the possible exit point as the screen had been pushed out. Staff searched the entire building and surrounding outside area and neighborhood near by. The local police were notified as well as R1's responsible party and Doctor. A missing person's report was filed and the search continued by the facility staff until 9:30pm.

On 8/10/22 at approximately 1:15pm a good Samaritan found R1 outside their home in Santa Ana at the corner of Edinger and Van Ness and called the responsible party. Responsible Party picked up R1 and brought him to the facility. R1 did not have injuries and was taken to the hospital.

No citations issued at this time. Mr. Nguyen and Ms. Mims were reminded that an elopement plan will need to be put into place when R1 returns and facility staff must be sufficient to meet R1's needs. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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