306005636-8-11-2022-22-AS-SSAS-CJ53VG-20220909183503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 08/10/2022
Date Signed: 08/11/2022 08:43:31 AM

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
04/28/2021 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210428152302

FACILITY NAME:	MAINPLACE SENIOR LIVING		FACILITY NUMBER:	306005636
ADMINISTRATOR:	MICHAEL MARION		FACILITY TYPE:	740
ADDRESS:	1800 1832 W. CULVER AVENUE		TELEPHONE:	(714) 978-2534
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	153	CENSUS: 75	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Phat Nguyen		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff did not adequately supervise resident resulting in multiple falls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to deliver the findings for the above complaint allegations. Upon arrival, LPA met with Phat Nguyen. The investigation consisted of interviews with Administrators Kathleen Olson and Brianna Boyd, staff, and witnesses as well as documentation from the facility. The following was determined:
R1 was admitted into the facility on 2/15/21. According to records reviewed, R1 needed assistance with ADL’s, was non-ambulatory and a fall risk due to diagnosis. R1 was non-ambulatory and used a wheelchair for mobility. R1 could not leave the facility unassisted and needed assistance with transfers to his wheelchair. Records and interviews further disclosed that R1 had approximately 15 unwitnessed falls from 3/4/21 to 4/16/21. R1 also left the facility at least 6 times without staff knowledge. R1 was returned by staff, good Samaritans or law enforcement. R1’s doctor and family were made aware of R1’s falls and eloping behavior. R1 was issued an eviction notice on 4/16/22 and moved from the facility on 4/28/21.
Based upon interviews and a review of records this allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report and appeal rights were provided to Phat Nguyen.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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