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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005636
Report Date: 11/02/2022
Date Signed: 11/02/2022 03:19:45 PM


Document Has Been Signed on 11/02/2022 03:19 PM - 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: 78DATE:
11/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rhon HipolitoTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of following up on an incident report received by the Department on 10/31/2022. LPA met with Administrator In Training (AIT) Rhon Hipolito and Wellness Director (WD) Kim Mims and explained the reason for the visit.

LPA Gutierrez reviewed Resident 1's (R1) Physician's Report dated 10/05/2022 and Resident Face Sheet from Skilled Nursing Facility (SNF) Leisure Court Nursing Center dated 9/22/2022. LPA found that R1 had diagnoses which included, Chronic Ischemic Heart Disease, Personal history of Transient Ischemic Attack, Hypertension, and Alzheimer’s disease. R1 also had a Physician’s Order dated 6/20/2022 which indicated, Do Not Attempt Resuscitation (DNR).

At this time no deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. LPA conducted an exit interview, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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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