306005636-8-11-2022-22-AS-SSAS-CJ53Y9-20220909183933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005636
Report Date: 08/10/2022
Date Signed: 08/11/2022 08:42:31 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
01/03/2022 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220103122410

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: 75	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Phat Nguyen		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident did not receive meals.
Facility staff mismanage resident's medications.
Facility does not have sufficient staff to meet residents' needs.

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 Administrator Phat Nguyen, staff, and witnesses as well as documentation from the facility. The following was determined:

Resident #1(R1) was admitted into the facility on 12/6/13. Staff were responsible for administering R1's medications. On 5/11/21 R1's physician notified facility staff via written letter, that R1 could administer all her own medications. On 12/28/21 the same Physician provided written certification that staff were to manage all medications. R1's Physician also discontinued several of R1's medications. Interviews disclosed that staff were following doctor's orders.

LPA also reviewed the Meal Check in report from 11/22/21-12/30/21 for R1. The report disclosed that R1 did receive meals and sometimes refused meals. Dinner was marked as not being given for all of the residents' on some days during the month. Staff confirmed that the box was overlooked and residents' did eat dinner.

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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Control Number 22-AS-20220103122410

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: 08/10/2022

NARRATIVE

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Staffing schedules were reviewed from 10/31/21-1/8/22 and interviews were conducted. Facility staffing during those dates was three care staff on the morning shift, two care staff on the PM shift and one care staff on the NOC shift.

Based upon interviews and a review of records the allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of this report and appeal rights were provided to Phat Nguyen.

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

LIC9099 (FAS) - (06/04)

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