Inspection Reports for Mainplace Senior Living
1800 W Culver Ave, Orange, CA 92868, United States, CA, 92868
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised did not have sufficient evidence. However, some substantiated complaints identified issues primarily with resident care and supervision, staff training, and timely reporting of incidents. Notably, a serious deficiency was cited in April 2024 for failure to provide timely medical attention after multiple falls resulting in hospitalization, and in June 2023 for improper eviction procedures. The facility also had repeated findings related to inadequate staff training, especially regarding dementia care, and occasional lapses in maintaining a clean and safe environment or operable call systems. The most recent report from October 15, 2025, was an administrative conference with no deficiencies cited, suggesting some improvement in compliance.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Capacity: 153
Deficiencies: 0
Oct 15, 2025
Visit Reason
The visit was an office type inspection involving an Informal Conference to discuss administrative organization and the Department's consultation role.
Findings
The report documents discussions held during the Informal Conference with facility and Department representatives, agreements on providing updated administrative documents by October 20, 2025, and an exit interview was conducted. No specific deficiencies or violations are detailed in this report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruby Racca Magao | Clinical Director | Present at the Informal Conference. |
| Ann Zavela | California Market Leader | Present at the Informal Conference. |
| Roanne Delos Reyes | California Clinical Market Leader | Present at the Informal Conference. |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager. |
| Claudia Gutierrez | Licensing Program Analyst | Named as Licensing Program Analyst. |
| Rose Ruppert | Licensing Program Analyst | Present representing the Department. |
| Marina Stanic | Regional Manager | Present representing the Department. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 153
Deficiencies: 0
Oct 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on May 31, 2024, alleging that facility management staff is never available, food service is inadequate, and the facility failed to safeguard residents' property.
Findings
The investigation found conflicting information regarding the allegations. Some residents and staff reported management was available and food service was adequate, while one resident reported poor food quality and concerns about management availability. The allegation of stolen resident property was unsubstantiated due to lack of evidence. No citations were issued.
Complaint Details
The complaint included allegations that facility management staff is never available, food service is inadequate, and the facility failed to safeguard resident’s property. The investigation was unsubstantiated due to conflicting information and lack of preponderance of evidence.
Report Facts
Capacity: 153
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonwinn Hipolito | Executive Director | Met during the investigation and provided statements regarding management availability and food service |
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 153
Deficiencies: 0
Oct 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not provide adequate supervision resulting in a physical altercation between residents in care.
Findings
The investigation found conflicting information regarding the alleged inadequate supervision and physical altercation between residents. One of eight individuals confirmed the allegation, but other interviews and document reviews did not substantiate it. Therefore, the allegation was deemed unsubstantiated and no citations were issued.
Complaint Details
The complaint alleged inadequate staff supervision leading to a physical altercation between residents. The allegation was investigated but found unsubstantiated due to conflicting evidence and lack of preponderance of proof.
Report Facts
Complaint received date: Mar 21, 2025
Investigation visit start time: 1300
Investigation visit end time: 1555
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Rhonwinn Hipolito | Executive Director | Facility administrator met during the investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 153
Deficiencies: 0
Sep 26, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of lack of care and supervision resulting in a resident sustaining a fracture.
Findings
The investigation found that Resident #1 sustained a fall resulting in a hip fracture, but it was unclear if the fall was due to lack of care and supervision. There was insufficient evidence to substantiate the allegation, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged lack of care and supervision resulting in a resident sustaining a fracture. The allegation was unsubstantiated due to insufficient evidence to prove or refute the claim.
Report Facts
Complaint Control Number: 22
Complaint Control Number: 20240418131913
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hanna Gough | Licensing Program Analyst | Investigator conducting the complaint investigation |
| Rhon Hipolito | Executive Director | Facility representative met during investigation and exit interview |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Follow-Up
Census: 109
Capacity: 153
Deficiencies: 0
Sep 3, 2025
Visit Reason
The visit was an unannounced case management follow-up regarding a Death Report received for Resident 1 on August 28, 2025, and to conduct a Health and Safety inspection.
Findings
During the inspection, the facility was found to be in compliance with no deficiencies cited. Resident rooms were properly furnished, medication was securely stored, fire extinguishers were charged and up to date, and safety systems were operable. No immediate threats to resident health or safety were observed.
Report Facts
Capacity: 153
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the unannounced case management visit and inspection |
| Briana Garcia | Business Office Manager | Met with Licensing Program Analyst during the inspection |
| Rhonwinn Hipolito | Administrator/Director | Facility Administrator/Director named in the report |
Inspection Report
Follow-Up
Census: 107
Capacity: 153
Deficiencies: 0
Jun 19, 2025
Visit Reason
An unannounced case management visit was conducted to follow up regarding an incident report received by Community Care Licensing on June 18, 2025, and to perform a Health and Safety inspection.
Findings
The inspection found that resident bedrooms were properly furnished, utilities and services were operational, food supplies met regulatory requirements, and fire extinguishers were fully charged. No immediate threats to resident health or safety were observed, and no deficiencies were cited.
Report Facts
Water temperature: 113.9
Food supply: 2
Food supply: 7
Fire extinguisher service date: Oct 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the inspection and case management visit |
| Monica Guardian | Administrator in Training | Met with Licensing Program Analyst during inspection |
| Briana Garcia | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Ruby Racca-Magao | Clinical Director | Met with Licensing Program Analyst during inspection |
| Rhonwinn Hipolito | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 153
Deficiencies: 0
Jun 16, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2023-03-01 regarding insufficient staff to meet residents' needs and bathrooms being made inaccessible to residents.
Findings
The investigation found no corroboration for the allegations after interviews with residents and staff, observations, and record reviews. Staffing levels were adequate, and bathrooms were accessible except for one locked memory care bathroom due to safety concerns. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, observations, and document review. No citations were issued.
Report Facts
Staff on assisted living side: 5
Staff on memory care unit: 4
Resident interviews conducted: 6
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine Rodriguez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ruby Racca-Magao | Wellness Director | Met with during the investigation and exit interview |
| Briana Garcia | Business Office Manager | Met with during the investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 153
Deficiencies: 2
Apr 29, 2025
Visit Reason
An unannounced complaint investigation was conducted following allegations of lack of facility supervision resulting in serious injuries and multiple falls, and failure to provide timely medical attention to an injured resident.
Findings
The investigation substantiated that Resident #1 suffered multiple falls over approximately three months without documented re-evaluation of care needs, resulting in serious injuries requiring hospitalization. The facility failed to provide timely medical attention after a fall on December 20, 2024, causing a delay of over five hours in medical services. The facility violated its own policies and regulatory requirements.
Complaint Details
The complaint investigation was substantiated. Allegations included lack of facility supervision causing serious injuries and multiple falls, and failure to provide timely medical attention. Evidence showed multiple unwitnessed falls of Resident #1, inadequate monitoring, failure to reassess care needs, and delayed emergency response violating facility policy.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Basic services including care and supervision were not met as Resident #1 suffered six falls over three months without documented re-evaluation of care needs, resulting in serious injury and hospitalization. | Type A |
| Failure to immediately telephone 9-1-1 after an injury resulting in imminent threat to resident's health; a 5 hour and 20 minute delay in medical attention occurred after a fall on 12/20/2024. | Type A |
Report Facts
Resident falls: 6
Delay in medical attention (minutes): 320
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ervin Nario | Health and Wellness Coordinator | Met with Licensing Program Analyst during investigation and exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 117
Capacity: 153
Deficiencies: 0
Jan 15, 2025
Visit Reason
Licensing Program Analyst Claudia Gutierrez made an unannounced visit to conduct a Required/Annual Inspection of the Mainplace Senior Living Facility.
Findings
The inspection found the facility to be in compliance with all regulations, with no deficiencies cited. Observations included operable signal systems, proper food supplies, functional safety equipment, secure medication storage, and well-maintained resident rooms and common areas.
Report Facts
Food supply duration: 2
Food supply duration: 7
Fire extinguisher service date: Oct 14, 2024
Water temperature range: 105.9
Water temperature range: 116.4
Resident files reviewed: 10
Staff files reviewed: 5
Residents interviewed: 10
Staff interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonwinn Hipolito | Executive Director | Met with Licensing Program Analyst during inspection and discussed inspection purpose |
| Claudia Gutierrez | Licensing Program Analyst | Conducted the inspection visit |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 153
Deficiencies: 0
Sep 18, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not ensuring air conditioning was maintained in good repair and were not preventing physical altercations between residents.
Findings
The investigation found conflicting information regarding the air conditioning repair status and no evidence of physical altercations between residents. Observations showed the air conditioning was operational and residents were undisturbed. Due to lack of preponderance of evidence, the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to maintain air conditioning and failure to prevent physical altercations. Interviews with staff and residents yielded conflicting information about air conditioning, and no physical altercations were observed or confirmed.
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Ruby Racca-Magao | Wellness Director | Met with investigators during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 153
Deficiencies: 0
Jul 23, 2024
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that a resident did not receive medication correspondence sent to the facility in a timely manner.
Findings
The investigation found that residents R1, R2, R3, and R4 were assessed as capable of managing their own medication. Interviews and record reviews showed mixed reports about medication delivery, with no active grievances filed. The department was unable to substantiate the allegation due to insufficient evidence.
Complaint Details
The complaint alleged that a resident did not receive medication correspondence in a timely manner. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 153
Resident census: 114
Number of residents' records reviewed: 5
Number of resident interviews attempted/conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Rhonwinn Hipolito | Executive Director | Facility administrator present during the visit |
| Ruby Raccamagao | Wellness Director | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 153
Deficiencies: 2
Jun 21, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the licensee does not ensure that staff are adequately trained.
Findings
The investigation found that eight of eight direct care staff training records did not meet the required 40 hours of training, including specific dementia care and other required topics. Additionally, five of eight staff files lacked proof of first aid training. The allegation was substantiated based on staff interviews and record reviews.
Complaint Details
The complaint was substantiated. The allegation was that the licensee does not ensure that staff are adequately trained. The preponderance of evidence standard was met based on staff interviews and record reviews.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met in five of eight care staff files, posing a potential safety risk. | Type B |
| Staff training records did not contain the required 40 hours of training, including dementia care and other specific training, in eight of eight care staff files, posing a potential health and safety risk. | Type B |
Report Facts
Staff training hours missing: 40
Staff files missing first aid training proof: 5
Estimated days for correction: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Charlie Marinko | Administrator in Training | Met with Licensing Program Analyst during investigation |
| Ruby Racca-Magao | Wellness Director | Participated in exit interview and was involved in plan of correction |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 153
Deficiencies: 0
May 8, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident sustained multiple falls while in care.
Findings
The investigation found that 7 of 7 individuals either denied or were unable to support the allegation. The department was unable to ascertain if the allegation occurred as reported and deemed the allegation unsubstantiated.
Complaint Details
The complaint alleged that a resident sustained multiple falls while in care. The allegation was investigated through interviews, document review, and observations but was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 153
Census: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Evaluator | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 153
Deficiencies: 2
May 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-02-08 regarding resident bruising and unsafe interactions among residents.
Findings
The investigation substantiated that Resident 1 sustained multiple bruises not consistent with falls, and Resident 2 engaged in unsafe behaviors including yelling and biting Resident 1. Violations of California Code of Regulations Title 22, Division 6 were cited.
Complaint Details
The complaint investigation was substantiated based on interviews and document review. Allegations included Resident 1 sustaining multiple bruises and unsafe interactions among residents, including Resident 2's abusive behavior. The preponderance of evidence standard was met.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents were not accorded dignity in their personal relationships, evidenced by Resident 1 sustaining multiple bruises while in care. | Type B |
| Residents were not provided safe, healthful, and comfortable accommodations as Resident 1 was abused by Resident 2 while in care. | Type B |
Report Facts
Capacity: 153
Census: 111
Deficiency count: 2
Plan of Correction Due Date: May 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Luz Adams | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 153
Deficiencies: 1
May 8, 2024
Visit Reason
The visit was conducted as a Case Management investigation into a complaint regarding the facility's failure to report an attack resulting in injury to the Regional Office.
Findings
The facility failed to report a resident attack that caused injury and required police involvement, violating California Code of Regulations Title 22. This failure poses a potential health and safety risk to residents.
Complaint Details
Investigation into complaint control number 22-AS-20230208162544 found the facility did not report an attack between residents that resulted in injury and police involvement. The complaint is substantiated by in-house notes and staff interviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report within seven days of an incident involving psychological abuse and police involvement. | Type B |
Report Facts
Census: 111
Total Capacity: 153
Plan of Correction Due Date: May 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted staff interviews and authored the report |
| Luz Adams | Licensing Program Manager | Supervisor of the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 153
Deficiencies: 0
Apr 23, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff did not safeguard a resident's belongings and were not answering communications from the resident's responsible person.
Findings
The investigation included interviews and document reviews but found insufficient evidence to prove or refute the allegations; therefore, all allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included failure to safeguard resident belongings and failure to answer communications. Evidence was inconclusive, and the department was unable to ascertain if the allegations occurred as reported.
Report Facts
Complaint Control Number: 22-AS-20240415111317
Capacity: 153
Census: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Rhonwinn Hipolito | Administrator | Facility administrator met during investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 153
Deficiencies: 0
Apr 10, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that the facility did not safeguard residents' belongings in rooms and did not report theft.
Findings
The investigation included interviews with staff, residents, and witnesses, and document review. The allegations were found to be unsubstantiated due to lack of sufficient evidence to prove or refute the claims.
Complaint Details
The complaint involved two allegations: failure to safeguard residents' belongings and failure to report theft. Interviews and document review revealed no corroboration of unauthorized entry or theft, and the facility had informed the resident's family and police regarding a reported medication theft. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 153
Census: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rhonwinn Hipolito | Executive Director | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 153
Deficiencies: 0
Apr 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-12 regarding staffing adequacy and required postings at the facility.
Findings
The investigation included interviews with staff, residents, and witnesses, as well as document and posting observations. Both allegations—that the facility did not have appropriate staffing to meet residents' needs and that the facility lacked required postings—were found to be unfounded.
Complaint Details
The complaint investigation was based on two allegations: insufficient staffing and missing required postings. Interviews with nine individuals, including staff and residents, mostly denied the allegations. Observations confirmed required postings were present. The allegations were determined to be unfounded.
Report Facts
Number of interviews conducted: 9
Facility census: 110
Facility capacity: 153
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Rhonwinn Hipolito | Executive Director | Facility representative met during the investigation |
| Luz Adams | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Plan of Correction
Census: 112
Capacity: 153
Deficiencies: 1
Mar 14, 2024
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted in conjunction with complaint control #22-AS-20230629084645 and a citation issued on 01/10/2024 to verify correction of previously cited deficiencies.
Findings
The licensee failed to correct deficiencies related to personnel records training and orientation, specifically in-service training for direct care staff serving residents with dementia, as required by Title 22 regulations. The deficiencies remain uncured as of the visit date.
Complaint Details
The visit was conducted in conjunction with complaint control #22-AS-20230629084645.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Records (1) training and orientation shall be documented: at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter. For staff who provide direct care to residents with dementia, the licensee shall document orientation and in-service training as specified in Section 87707(a)(1) and (a)(2). This requirement is not met as evidence by LPA's observations and file reviews showing S1, S2, and S3 do not meet Title 22 training requirements. | Type B |
Report Facts
Capacity: 153
Census: 112
Deficiencies cited: 1
POC Due Date: Mar 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the Plan of Correction visit and cited deficiencies. |
| Brianna Garcia | Business Office Manager | Facility representative who met with the Licensing Program Analyst during the visit. |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 153
Deficiencies: 2
Feb 14, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2023-11-20 regarding medication administration, resident comfort, staffing adequacy, provision of admissions agreement, and communication with authorized representatives.
Findings
The investigation found that although some allegations had some basis, there was insufficient evidence to substantiate violations. Two Type B deficiencies were cited related to incomplete resident records and delayed provision of records to the authorized representative. Other allegations such as medication administration, temperature comfort, staffing levels, and communication were found unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated overall. Allegations included failure to administer eye drops as prescribed, inadequate temperature, insufficient staffing, failure to provide admissions agreement, and failure to communicate health changes. The investigation included interviews, record reviews, and site tours. Two deficiencies were cited related to record keeping and timely access to records.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Incomplete resident records due to misplaced admission agreement, violating CCR 87506(a). | Type B |
| Failure to provide resident's authorized representative access to records within two business days, violating CCR 87468.2(a)(19). | Type B |
Report Facts
Capacity: 153
Census: 110
Deficiencies cited: 2
Plan of Correction Due Date: Mar 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
| Rhonwinn Hipolito | Administrator | Facility administrator present during inspection and assisted with the visit |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 153
Deficiencies: 1
Jan 31, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not adequately supervise a resident, resulting in multiple wanderings from the facility.
Findings
The investigation substantiated the allegation that staff failed to adequately supervise the resident, leading to multiple wanderings which posed an immediate health and safety risk. A deficiency was cited under Title 22 Division 6 of the California Code of Regulations.
Complaint Details
The complaint was substantiated. The allegation was that staff did not adequately supervise a resident, resulting in multiple wanderings from the facility. Evidence included incident reports and facility disclosures confirming the resident's unsupervised wanderings and the associated risks.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| "Care and supervision" means the facility assumes responsibility for ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by the facility's failure to assume responsibility for the resident's wandering behavior, resulting in multiple wanderings posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 153
Census: 108
Deficiency Type: 1
Plan of Correction Due Date: Feb 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Phat T. Nguyen | Administrator | Facility administrator named in the report |
| Chasidy Washington | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 153
Deficiencies: 0
Jan 31, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility windows and the facility gate were not secured.
Findings
The investigation found conflicting information regarding the security of the facility windows and gate. The Licensing Program Analyst observed that windows in the memory care unit were latched and alarmed, and the gate was self-latching with an operable lock. Due to insufficient evidence, the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated due to conflicting information and lack of preponderance of evidence to prove the alleged violations regarding unsecured windows and gate.
Report Facts
Capacity: 153
Census: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Phat T. Nguyen | Administrator | Facility administrator named in the report |
| Chasidy Washington | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Elizabeth Mendoza | Community Liaison | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 153
Deficiencies: 1
Jan 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints alleging inadequate staffing to meet residents' needs, residents being left unattended, and untrained staff providing care and supervision.
Findings
The investigation found conflicting information regarding staffing adequacy and residents being left unattended, resulting in those allegations being unsubstantiated. However, the allegation that untrained staff were providing care and supervision was substantiated based on interviews and staff training record reviews, revealing deficiencies in required dementia care training.
Complaint Details
The complaint investigation was triggered by allegations received on 06/29/2023 regarding inadequate staffing, residents being left unattended, and untrained staff providing care. The allegation of untrained staff was substantiated, while the others were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Records (1) training and orientation shall be documented: (A) at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter. (B) For staff who provide direct care to residents with dementia, the licensee shall document orientation and in-service training as specified. This requirement was not met as staff S1, S2, and S3 did not meet Title 22 training requirements. | Type B |
Report Facts
Capacity: 153
Census: 109
Staffing levels: 4
Staffing levels: 2
Staffing levels: 2
Staffing levels: 1
Deficiency plan of correction due date: Jan 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Chasidy Washington | Business Office Director | Met with Licensing Program Analyst during investigation and exit interview |
| Noemi Otero | Receptionist | Met with Licensing Program Analyst during investigation |
| Rhoniwnn Hipolito | Administrator | Facility administrator named in the report |
| Staff 1 | Staff member whose training records were reviewed and found deficient | |
| Staff 2 | Staff member whose training records were reviewed and found deficient | |
| Staff 3 | Staff member whose training records were reviewed and found deficient |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 153
Deficiencies: 0
Jan 4, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not addressing residents' fall risk.
Findings
The investigation included interviews with residents and staff, a review of documentation, and observations. The allegation was not corroborated by interviews or evidence, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff were not addressing resident's fall risk. Interviews with 7 residents and 2 staff members did not corroborate the allegation. Documentation showed a resident with dementia had a fall, but the fall was not due to staff neglect. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Resident interviews conducted: 7
Staff interviews conducted: 2
Facility capacity: 153
Facility census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Rhon Hipolito | Executive Director | Met with investigator and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 153
Deficiencies: 1
Dec 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/27/2023 regarding the facility's failure to report theft of a resident's personal belongings and staff going through residents' personal belongings.
Findings
The complaint that the facility did not report theft of a resident's personal belongings was substantiated, as the facility filed a police report 18 days after the discovery of stolen property valued at $400, exceeding the 36-hour reporting requirement. The allegation that staff were going through residents' personal belongings was unsubstantiated due to conflicting information and lack of preponderance of evidence.
Complaint Details
The complaint investigation involved two allegations: 1) the facility did not report theft of a resident's personal belongings, which was substantiated; 2) staff were going through residents' personal belongings, which was unsubstantiated. The substantiated allegation cited a violation of California Code of Regulations, Title 22, Division 6, Chapter 8.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to report stolen property valued at $400 to law enforcement within 36 hours as required by the facility's Theft and Loss Policy. | Type B |
Report Facts
Days late filing police report: 18
Value of stolen property: 400
Capacity: 153
Census: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation. |
| Rhonwinn Hipolito | Executive Director | Facility administrator involved in interviews and exit meeting. |
| Elizabeth Bran Mendoza | Director of Sales and Marketing / Community Liaison | Met with Licensing Program Analyst during investigation. |
| Ruby Raccamagao | Wellness Director | Participated in exit interview and received report copy. |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 153
Deficiencies: 0
Nov 20, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not provide medications to a resident as prescribed and that staff spoke to a resident in an inappropriate manner.
Findings
The investigation found the allegation regarding medication administration to be unfounded, as interviews and documentation confirmed the resident self-administered medications. The allegation of inappropriate staff communication was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint involved two allegations: 1) staff did not provide medications to a resident as prescribed, which was found to be unfounded; 2) staff spoke to a resident in an inappropriate manner, which was unsubstantiated.
Report Facts
Capacity: 153
Census: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation |
| Rhon Hipolito | Administrator | Met with during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 153
Deficiencies: 0
Nov 20, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that facility staff did not answer resident's calls for assistance.
Findings
The investigation found that staff respond to call lights and assistance requests in a timely manner, with sufficient staffing levels. Observations and interviews indicated no substantiated failure to respond to calls. The allegation was determined to be unfounded with no deficiencies cited.
Complaint Details
The complaint alleging that staff did not answer resident's calls for assistance was investigated and found to be unfounded based on interviews, documentation review, and observations.
Report Facts
Facility capacity: 153
Resident census: 106
Inspection visit dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonwinn Hipolito | Administrator / Executive Director | Met during investigation and named in findings |
| Rosie Quiroz | Licensing Program Analyst | Conducted investigation and signed report |
| Jenifer Tirre | Licensing Program Analyst | Conducted joint unannounced visit |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 153
Deficiencies: 2
Nov 15, 2023
Visit Reason
An unannounced complaint investigation was conducted due to allegations that a resident sustained injuries from a fall while in care and had fallen multiple times.
Findings
The investigation found that the resident fell multiple times, including one fall requiring hospitalization, and was not re-assessed or re-appraised after the falls. The allegations were substantiated and deficiencies were cited related to failure to update the resident's appraisal and failure to arrange a meeting regarding significant change in condition.
Complaint Details
The complaint investigation was substantiated. The resident fell multiple times, including a fall on 6/28/22 that required hospitalization and resulted in significant change in condition. The facility failed to re-assess the resident or update the appraisal and failed to arrange required meetings.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to update resident appraisal in writing to note significant changes and keep appraisal accurate after falls. | Type A |
| Failure to arrange a meeting with resident, representative, and facility staff after significant change in resident's condition following a fall requiring hospitalization. | Type A |
Report Facts
Resident falls documented: 5
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report |
| Rhon Hipolito | Administrator | Met with Licensing Program Analyst during investigation and involved in findings |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 153
Deficiencies: 0
Oct 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 06/06/2023 regarding the facility not meeting residents' needs and improper cleaning of floors in resident rooms.
Findings
The investigation found that nine of ten interviewees denied the allegation that the facility does not meet residents' needs, and six of six residents confirmed timely staff response. Regarding floor cleaning, nine of ten interviewees denied the allegation, with maintenance and health staff confirming timely carpet cleaning upon request. Both allegations were deemed unfounded based on evidence gathered.
Complaint Details
The complaint investigation was triggered by allegations that the facility does not meet residents' needs and that floors in resident rooms are not cleaned properly. The allegations were found to be unfounded after interviews with residents, staff, and observations.
Report Facts
Capacity: 153
Census: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonwinn Hipolito | Executive Director | Met during investigation and provided information regarding facility operations and floor installations |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 102
Capacity: 153
Deficiencies: 0
Sep 19, 2023
Visit Reason
The visit was a Case Management - Other type of unannounced collateral visit conducted by Licensing Program Analyst Andrea Mendivil to evaluate the facility and interview a resident.
Findings
No deficiencies were noted during the visit. An exit interview was conducted and a copy of the report was provided to the Executive Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonwinn Hipolito | Executive Director | Greeted the Licensing Program Analyst and was present during the visit. |
| Andrea Mendivil | Licensing Program Analyst | Conducted the collateral visit and resident interview. |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 102
Capacity: 153
Deficiencies: 1
Jul 5, 2023
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced case management visit to the facility to follow up on a 10-day complaint visit regarding missing required posters.
Findings
The See Something Say Something Poster was not posted in the main entryway as required, though Ombudsman posters were observed in other locations. The Executive Director acknowledged the issue and agreed to correct it. A Technical Assistance Advisory Note was issued.
Complaint Details
The visit was related to a 10-day complaint visit (Complaint # 22-AS-20230630114211 dated 6/30/23).
Deficiencies (1)
| Description |
|---|
| See Something Say Something Poster was not posted in the main entryway of the facility. |
Report Facts
Capacity: 153
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonwinn Hipolito | Executive Director | Met with Licensing Program Analyst during the visit and acknowledged the poster issue |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 153
Deficiencies: 0
Jun 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-04-10 alleging multiple issues including inadequate resident hygiene, feeding, response to calls for assistance, telephone answering, and timely medical care.
Findings
Based on interviews, document reviews, and observations, the allegations were either unfounded or unsubstantiated. Residents' hygiene needs were met, residents were adequately fed, staff responded to call buttons, the facility telephone was answered, and medical care was contacted timely. There was insufficient evidence to prove or refute the alleged violations; therefore, the allegations were deemed unsubstantiated or unfounded.
Complaint Details
The complaint included allegations that staff did not ensure residents' hygiene needs were met, did not adequately feed residents, did not respond to residents' calls for assistance, did not answer facility telephone, did not obtain medical care in a timely manner, and removed resident's personal items (ringbell camera). The allegation regarding removal of personal items was unfounded. Other allegations were unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 153
Census: 102
Number of interviews conducted: 9
Number of resident call buttons tested: 3
Number of calls made to facility: 3
Number of interviews not corroborating medical care allegation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rhonwinn Hipolito | Executive Director | Facility representative met during inspection and exit interview |
| Luz Adams | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 153
Deficiencies: 1
Jun 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-20 regarding an allegation of illegal eviction at the facility.
Findings
The facility failed to provide proper 30-day eviction procedures and did not include the necessary information as required by Title 22 regulations. The allegation of illegal eviction was substantiated based on the preponderance of evidence.
Complaint Details
The complaint investigation was substantiated. The allegation was illegal eviction. The facility issued a 30-day eviction notice without meeting all regulatory requirements, and court approval for unlawful detainer was received but not yet issued to the resident.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not comply with proper eviction procedures which poses an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
Capacity: 153
Census: 102
Plan of Correction Due Date: Jun 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Luz Adams | Licensing Program Manager | Named in relation to the investigation and plan of correction |
| Chasidy Washington | Business Office Coordinator | Met with Licensing Program Analyst during investigation |
| Elizabeth Mendoza | Coordinator | Met with Licensing Program Analyst during investigation |
| Rohn Hipolito | Administrator | Present via telephone during investigation |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 153
Deficiencies: 4
Jun 10, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 03/17/2023 regarding medication administration, provision of resident records to emergency personnel, care and supervision, cleanliness, call button functionality, reporting requirements, and phone answering.
Findings
The investigation substantiated allegations that the facility failed to provide a clean and sanitary environment, had inoperable resident call buttons, did not follow reporting requirements, and did not answer phone calls promptly. Other allegations related to medication administration, provision of resident records to emergency personnel, and care and supervision were unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Patricia Velazquez. The complaint control number is 22-AS-20230317144713. The allegations included failure to administer medication, failure to provide resident's record to emergency personnel, failure to provide care and supervision, failure to maintain a clean and sanitary environment, inoperable call buttons, failure to follow reporting requirements, and failure to answer phone calls. The investigation found some allegations substantiated and others unsubstantiated.
Severity Breakdown
Type B: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility was not kept clean, safe, sanitary, and in good repair, posing a potential risk to residents. | Type B |
| Pull cord signal system was not operable in room 334, posing a potential risk to residents. | Type B |
| Licensee failed to submit timely incident reports as required by regulation. | Type B |
| Facility phone was not answered promptly and appropriately, posing a potential risk to residents. | Type B |
Report Facts
Capacity: 153
Census: 100
Deficiencies cited: 4
Plan of Correction Due Dates: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Sanchez | Medication Technician | Met with during investigation and named in exit interview |
| Rhonwinn Hipolito | Executive Director | Spoke with on phone during investigation and confirmed some findings |
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 153
Deficiencies: 0
May 25, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations regarding cleanliness and resident care at Mainplace Senior Living Facility.
Findings
All allegations including unclean resident rooms, unkempt resident appearance, unclean bathrooms, lack of toilet paper, and unclean mattresses were investigated and found to be unsubstantiated or unfounded based on observations and staff interviews.
Complaint Details
The complaint investigation was triggered by allegations that staff did not ensure residents' rooms and bathrooms were clean, residents appeared unkempt due to neglect, residents lacked toilet paper, and mattresses were not clean. The investigation found no preponderance of evidence to substantiate these allegations; one allegation regarding mattress cleanliness was deemed unfounded.
Report Facts
Capacity: 153
Census: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rhon Hipolito | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Census: 102
Capacity: 153
Deficiencies: 0
Mar 21, 2023
Visit Reason
An unannounced Case Management visit was conducted to Mainplace Senior Living to provide consultation regarding Title 22 Regulation and the Health and Safety Code, related to complaint control number 22-AS-20230317144713.
Findings
No deficiencies were issued during this Case Management visit. Extensive consultation was provided and the importance of attending informational calls was emphasized.
Complaint Details
The visit was related to a complaint with control number 22-AS-20230317144713. No deficiencies were found during the complaint visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhonwinn Hipolito | Executive Director | Met with Licensing Program Analyst during the Case Management visit and had questions regarding statute and regulation. |
| Patricia Velazquez | Licensing Program Analyst | Conducted the unannounced Case Management visit and provided consultation. |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 153
Deficiencies: 0
Dec 14, 2022
Visit Reason
An unannounced complaint investigation was conducted due to allegations that resident's medication was not administered as prescribed, staff were not properly trained, staff did not answer the facility phone, and the facility was in disrepair.
Findings
The investigation found conflicting information from staff and residents regarding the allegations. Medication administration records were reviewed but not time-stamped, making exact timing unclear. Staff training records showed required training was completed. Phone calls made during the investigation were answered by care staff. Facility plumbing was operational and no clear evidence of disrepair or ventilation issues was found. Due to insufficient evidence, the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred. Allegations included medication not administered as prescribed, inadequate staff training, unanswered facility phone, and facility disrepair.
Report Facts
Capacity: 153
Census: 88
Complaint Control Number: 22-AS-20220802095010
Number of residents interviewed: 11
Number of staff interviewed: 6
Phone call attempts: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Phat T. Nguyen | Administrator / former Executive Director | Interviewed regarding staff training and phone answering allegations |
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation |
| Rhon Hipolito | Administrator In Training | Met with Licensing Program Analyst during investigation and exit interview |
| Kim Mims | Wellness Director | Interviewed regarding medication administration allegation |
Inspection Report
Census: 81
Capacity: 153
Deficiencies: 0
Nov 10, 2022
Visit Reason
The visit was conducted to amend Complaint #22-AS-20200929093348 by adding additional information without changing the original finding of Unsubstantiated.
Findings
The amendment to the complaint did not change the finding, which remained Unsubstantiated. An exit interview was conducted and a copy of the report was provided to the facility administrator.
Complaint Details
The visit was related to Complaint #22-AS-20200929093348. The finding was Unsubstantiated and remained unchanged after the amendment.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the case management visit and amendment of the complaint. |
| Rhon Hipolito | Administrator | Facility administrator met during the visit and received the report. |
Inspection Report
Follow-Up
Census: 78
Capacity: 153
Deficiencies: 0
Nov 2, 2022
Visit Reason
Licensing Program Analyst Claudia Gutierrez made an unannounced visit to follow up on an incident report received by the Department on 10/31/2022.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst reviewed Resident 1's medical records and confirmed diagnoses and physician orders, including a Do Not Attempt Resuscitation order.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rhon Hipolito | Administrator In Training | Met with Licensing Program Analyst during the visit. |
| Kim Mims | Wellness Director | Met with Licensing Program Analyst during the visit. |
| Claudia Gutierrez | Licensing Program Analyst | Conducted the unannounced visit and inspection. |
| Armando J Lucero | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 79
Capacity: 153
Deficiencies: 0
Oct 26, 2022
Visit Reason
Licensing Program Analyst Claudia Gutierrez made an unannounced visit to conduct a Required/Annual Inspection of the facility.
Findings
No deficiencies were cited during the inspection. Technical Advisories were given regarding emergency care requirements in resident files and facility policies on resident screening, staff screening, visitation, COVID-19 protocols, infection control, PPE, staffing, and staffing shortages.
Report Facts
Resident files reviewed: 8
Resident files with unmet emergency care requirements: 3
PPE supply: 30
Food supply: 2
Food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the inspection and gave Technical Advisories |
| Rhon Hipolito | Administrator in Training | Met with Licensing Program Analyst during inspection |
| Kim Mims | Wellness Director | Arrived during inspection and reviewed facility policies with Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 153
Deficiencies: 1
Oct 26, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident's call button was in disrepair.
Findings
The investigation confirmed that the resident call button system was inoperable, with call button lights broken and ignored by staff. The allegation was substantiated based on interviews and observations.
Complaint Details
The complaint alleged that the resident's call button was in disrepair. The allegation was substantiated after investigation and interviews with staff and administration.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility's entire call button system is inoperable, posing a potential health and safety risk to residents in care. | Type B |
Report Facts
Estimated Days of Completion: 90
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Phat T. Nguyen | Administrator | Mentioned in interviews regarding call button system |
| Rhon Hipolito | Administrator In Training | Met during investigation and responsible for repair plan |
| Kim Mims | Wellness Director | Met during investigation |
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 153
Deficiencies: 2
Aug 10, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2021-01-02 regarding nonoperational facility dryers and resident laundry not washed, and nonoperational resident TV and cable.
Findings
The investigation substantiated that dryers were nonoperational from 12/2/20 to 12/4/20 causing laundry delays, and cable was nonoperational from 12/31/20 to 1/5/21 causing personal rights risk. Another complaint regarding food menus and administrator phone calls was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for issues with nonoperational dryers and cable causing potential health and personal rights risks. Another complaint about food menus and administrator phone calls was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice were not readily available due to nonoperational dryers. | Type B |
| The facility was not clean, safe, sanitary and in good repair due to nonoperational cable service for 4 days. | Type B |
Report Facts
Facility capacity: 153
Census: 75
Deficiencies cited: 2
Plan of Correction due date: Aug 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Mike Marion | Administrator | Admitted to dryer and cable issues during investigation |
| Phat Nguyen | Met with Licensing Program Analyst during inspection and received report | |
| Kim Mims | Wellness Director | Met with Licensing Program Analyst during inspection |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 153
Deficiencies: 0
Aug 10, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-04-28 alleging inadequate supervision of a resident resulting in multiple falls.
Findings
The investigation found that resident R1, admitted on 2021-02-15, was non-ambulatory and a fall risk with approximately 15 unwitnessed falls and multiple elopements from the facility. Despite these incidents, the allegation of inadequate supervision was determined to be unsubstantiated due to insufficient evidence to prove the violation occurred.
Complaint Details
The complaint alleged that facility staff did not adequately supervise a resident resulting in multiple falls. The allegation was found unsubstantiated after interviews and record reviews.
Report Facts
Unwitnessed falls: 15
Elopements: 6
Capacity: 153
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Michael Marion | Administrator | Facility administrator mentioned in the report |
| Kathleen Olson | Administrator interviewed during the investigation | |
| Brianna Boyd | Administrator interviewed during the investigation | |
| Phat Nguyen | Facility representative met during the investigation and exit interview | |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 153
Deficiencies: 0
Aug 10, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including residents not receiving meals, mismanagement of medications, and insufficient staffing to meet residents' needs.
Findings
The investigation found that the allegations were unsubstantiated based on interviews, documentation review, and staffing schedules. Resident #1's medication management followed physician orders, meal records showed residents did receive meals though some refusals occurred, and staffing levels were adequate during the reviewed period.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations did or did not occur.
Report Facts
Facility capacity: 153
Resident census: 75
Staffing levels: 3
Staffing levels: 2
Staffing levels: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Phat T. Nguyen | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 153
Deficiencies: 0
Aug 10, 2022
Visit Reason
The inspection visit was conducted to deliver the findings of three complaints related to the facility, including an incident involving a resident elopement.
Findings
Resident #1 eloped from the Memory Care unit on 8/9/22, prompting a search involving staff and local police. The resident was found safe the next day without injuries. No citations were issued, but the facility was reminded to implement an elopement plan and ensure sufficient staffing to meet the resident's needs.
Complaint Details
The visit was triggered by complaints #22-AS-20220103122410, #22-AS-20210102174521, and #22-AS-20210428152302. The resident elopement incident was investigated and substantiated by the report of the resident leaving the facility unassisted and being found outside the facility the next day.
Report Facts
Complaint numbers: 3
Time of resident missing: 375
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Phat T. Nguyen | Operations Manager | Named in relation to the resident elopement incident and facility staffing |
| Kimberly Mims | Wellness Director | Named in relation to the resident elopement incident and communication with Licensing Program Analyst |
| Michelle Reed | Licensing Program Analyst | Conducted the inspection and delivered complaint findings |
| Sheila Santos | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 153
Deficiencies: 0
Jul 26, 2022
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations that staff failed to escort Resident #1 to breakfast causing the resident to faint and failed to provide first aid to Resident #1.
Findings
The investigation found that Resident #1 refused to go to breakfast and self-administered medications without food, which caused the resident to faint and sustain a cut. Staff did not administer first aid as the resident refused assessment and declined hospital or doctor visits at that time. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated. Although the events may have occurred, there was insufficient evidence to prove violations. Resident #1 was non-ambulatory, capable of self-care, and self-administered medications. Staff reported the resident refused to go to breakfast and refused first aid assessment after fainting.
Report Facts
Facility capacity: 153
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Phat Nguyen | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 153
Deficiencies: 0
Jul 26, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that a resident was touched inappropriately by another resident.
Findings
The investigation included interviews with the administrator, staff, and resident, as well as a review of documentation. The allegation was found to be unfounded, meaning it was false, could not have happened, or was without a reasonable basis.
Complaint Details
The complaint alleged that Resident 2 grabbed Resident 1's buttocks on two occasions while staff were escorting Resident 1 to breakfast. Both Resident 2 and staff denied the incidents. The allegation was determined to be unfounded.
Report Facts
Facility capacity: 153
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Phat Nguyen | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 153
Deficiencies: 0
Jul 13, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the responsible party did not receive a copy of the admission agreement and did not receive a refund.
Findings
The investigation found the allegations to be unfounded, meaning the allegations were false, could not have happened, or were without a reasonable basis. The complaint was dismissed after interviews and document reviews.
Complaint Details
The complaint allegations were that the responsible party did not get a copy of the admission agreement and did not receive a refund. After investigation, including interviews with three interviewees who all denied the allegations, the complaint was deemed unfounded.
Report Facts
Capacity: 153
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Phat Nguyen | Administrator | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 68
Capacity: 153
Deficiencies: 0
May 17, 2022
Visit Reason
Licensing Program Analyst Claudia Gutierrez made an unannounced case management visit to follow up on a report submitted to the department on May 2, 2022.
Findings
Interviews were conducted with the Business Manager and Wellness Director. Based on these interviews, the resident involved in the report is no longer at the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Eldridge | Business Manager | Met with Licensing Program Analyst during the visit and stated he was on duty administrator. |
| Kimberly Mims | Wellness Director | Interviewed by phone during the visit. |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 153
Deficiencies: 0
Apr 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that facility staff failed to assist a resident with meal services and that the licensee was charging fees outside the admission agreement.
Findings
The investigation found that the allegations were unsubstantiated. Records showed the resident often refused meal escort services and was provided alternatives. The fee charges outside the admission agreement were resolved with adjustments and a signed agreement. The administrator was reminded to keep admission agreements current and clear on additional charges.
Complaint Details
The complaint involved two allegations: failure to assist a resident with meal services and charging fees outside the admission agreement. After interviews and record reviews, the allegations were found unsubstantiated due to insufficient evidence.
Report Facts
Resident refusals to be taken to dining room: 51
Facility capacity: 153
Resident census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and issued findings. |
| Briana Boyd | Interim Administrator | Facility representative involved in investigation and exit interview. |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 153
Deficiencies: 0
Apr 16, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2020-04-13 regarding multiple allegations about resident R1's care and facility conditions at Mainplace Senior Living Facility.
Findings
The investigation found that although several allegations were made against the facility staff and conditions, including failure to safeguard belongings, improper transport, and facility disrepair, the evidence was insufficient to substantiate the complaints. The allegations were deemed unsubstantiated after interviews, record reviews, and staff statements.
Complaint Details
The complaint involved allegations that staff did not ensure resident access to personal belongings, failed to safeguard belongings, did not assist with meals, improperly transported the resident, failed to intervene in verbal altercations, threatened eviction, and that the facility was in disrepair. The investigation concluded these allegations were unsubstantiated.
Report Facts
Refusals to be taken to dining room: 51
Facility capacity: 153
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and issued findings |
| Briana Boyd | Interim Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Jeffery Gollihar | Administrator | Named as facility administrator in report header |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
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