Mainplace Senior Living

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and witness as well as reviewed and obtained pertinent documentation such as skilled nursing discharge paperwork and inventory list. Regarding the allegations that facility staff did not safeguard resident's belongings and facility staff are not answering communications from resident's responsible person, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 02/22/2024 after hospitalization at a skilled nursing facility (SNF). Discharge paperwork indicated resident's needs included a wheelchair but inventory list at discharge stated resident had no belongings. Staff 1 (S1) stated assisting the resident out of bed at the SNF and assisting the resident into van. TheRead the full finding— CDSS inspection report, April 23, 2024 · control 22-AS-20240415111317

Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to complete additional interviews and deliver the findings on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of interviews with facility staff, residents, a resident family member, a witness, and document review. Two additional witnesses were contacted but could not be reached. Regarding the complaint allegation: Facility did not safeguard residents’ belongings in room. During the investigation interviews were conducted with facility staff, residents, and witnesses for a total of nine interviews. Continued on LIC9099C UnsubstantiatedRead the full finding— CDSS inspection report, April 10, 2024 · control 22-AS-20240112162107

Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to complete additional interviews and deliver the findings on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of interviews with facility staff, residents, a resident family member, a witness, and document review. Two additional witnesses were contacted but could not be reached. Regarding the complaint allegation: Facility did not have appropriate staffing to meet residents needs. During the investigation interviews were conducted with facility staff, residents, and witnesses for a total of nine interviews. Continued on LIC9099C UnfoundedRead the full finding— CDSS inspection report, April 10, 2024 · control 22-AS-20240112162107

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after explaining the purpose of the visit. Facility administrator was present to assist with the visit. The initial investigation visit was conducted at the facility on November 22, 2023. LPA requested and obtained partial resident records for resident R1, conducted a tour of the physical plant and interviewed multiple staff members. A follow-up visit took place on February 2, 2024. One staff interview with the facility's Executive Director was conducted. Additional records requested and obtained. A tour of R1's former unit was also conducted. Additional witness interviews conducted in person or via telephone on February 9, 2024. CONTINUED ON FORM LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, February 14, 2024 · control 22-AS-20231120213146

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Complaint Investigation for the purpose of delivering findings regarding the allegations mentioned above. LPA met with Business Office Manager, Chasidy Washington and Community Liason, Elizabeth Mendoza. Interviews were conducted with staff and Resident 1 (R1) regarding facility windows not being secured. Two out of three staff stated that facility windows are secure, have a latch, and a screen. One out of three staff stated the window in the resident room where R1 was thought to have exited, was not screened on at least one occasion. All three staff, however, confirmed R1 did not exit through their own bedroom window. R1 entered room 306, which was a different resident’s room, and exited through that window. On 8/16/22, LPA conducted initial complaint investigation inspection at the facility. At 3:50 p.m. LPA conducted a tour of the inside and outside of the facility. LPA observed facility windows within the meRead the full finding— CDSS inspection report, January 31, 2024 · control 22-AS-20220809112719

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Complaint Investigation for the purpose of delivering findings regarding the allegation mentioned above. LPA met with Business Office Manager, Chasidy Washington and Community Liason, Elizabeth Mendoza. On 8/10/22, the Department received an Unusual Incident Report (LIC624) stating that on 8/09/22 at approximately 3:25 p.m. staff noted Resident 1 (R1) missing. Staff notified Wellness Director (WD) Kimberly Mims and Executive Director (ED) Phat Nguyen. A search of the unit including bathroom areas, bedrooms, and closets was conducted. Window in resident room 306 identified as possible exit point. Search of facility and surrounding area was initiated and expanded to surrounding neighborhoods. Per Case Management visit dated 8/10/22, R1 was found on 8/10/22 at approximately 1:15 p.m. by a good Samaritan standing outside a home miles away from the facility. Per Physician Reported dated 7/29/2022, R1 is not able to lRead the full finding— CDSS inspection report, January 31, 2024 · control 22-AS-20220809112719

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on 06/29/23. LPA was greeted and granted entry into the facility by Receptionist Noemi Otero. LPA explained the reason for the visit. Business Office Director Chasidy Washington arrived shortly after. This agency has investigated the complaint alleging that facility does not staff appropriately to meet residents' needs. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Six of ten individuals interviewed denied the allegation. During the investigation LPA reviewed documents including the July, November and December 2023 staff schedule. On average there are four caregivers and two medication technicians for the morning shift, two to four caregivers and two medication technicians for the evening shift and two caregivers and one medication technician for theRead the full finding— CDSS inspection report, January 10, 2024 · control 22-AS-20230629084645

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by executive director (ED) Rhon Hipolito. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that staff are not addressing resident's fall risk. LPA De Perio conducted 7 resident interviews, of which 7 out of the 7 interviews did not corroborate with the allegation. LPA De Perio conducted a total of 2 staff interviews, of which also did not corroborate with the allegation by stating that staff are trained on the protocol for when a resident falls and is also advised to contact medical assistance immediately for the resident to obtain an evaluation. UnsubstantiatedRead the full finding— CDSS inspection report, January 4, 2024 · control 22-AS-20231226144300

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on 06/27/23. LPA was greeted and granted entry into the facility by Receptionist Noemi Otero. LPA explained the reason for the visit. Director of Sales and Marketing Elizabeth Bran Mendoza arrived shortly after. This agency has investigated the complaint alleging that the facility did not report theft of resident's personal belongings. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: One of ten individuals interviewed corroborated the allegation. Records reviewed by LPA Ramirez included the Mainplace Senior Living Theft and Loss Policy. Per Theft and Loss Policy “Lost or stolen property with a value of $100.00 or more will be reported to law enforcement within thirty-six (36) hours of the discovery of the loss or theft.” Records reviewed by LPA Ramirez inRead the full finding— CDSS inspection report, December 22, 2023 · control 22-AS-20230627074740

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz and (LPA) Jenifer Tirre conducted a joint unannounced visit for the purpose to deliver findings for complaint allegation listed above. LPA Quiroz and LPA Tirre were greeted and granted entry by Front desk receptionist and met with Executive Director (ED) Rhonwinn Hipolito and discussed purpose of today's visit. The ten day inspection visit was conducted on 10/3/2023 and a complaint follow up inspection visit was conducted on 10/17/2023. During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff, residents and other witnesses and documentation review but not limited to physician reports, needs and services plans and facility call log report. Regarding the allegation "Facility staff did not answer resident's calls for assistance" the investigation revealed the following: Interviews conducted with interviewees consisting of staff and residents concluded that there is enough staRead the full finding— CDSS inspection report, November 20, 2023 · control 22-AS-20230929113543

Licensing Program Analyst’s (LPA’s) Jenifer Tirre and Rosie Quiroz made an unannounced joint visit to conduct follow up into complaint Investigation. LPA's was greeted and granted entry by staff. LPA's identified themselves and discussed the purpose of the visit with Executive Director Rhonwinn Hipolito. During the visit, LPA Tirre conducted interviews and requested pertinent documents such as Physician’s Report and Personnel Report. During the investigation, Interviews were conducted with staff and residents, Pertinent documents were reviewed and requested. On 1/20/23 the department received allegations that facility staff did not provide medications to resident as prescribed. Per interviews conducted with staff five out of five staff confirmed there was no issues with prescribed medications provided to residents. Interviews with residents confirm that five out of five residents had no issues with receiving medications and that prescribed medications were administered. Interviews withRead the full finding— CDSS inspection report, November 20, 2023 · control 22-AS-20230120095133

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez, regarding the allegations mentioned above. LPA met with Administrator (AD) Rhon Hipolito and explained the purpose of the visit. Interviews were conducted with two staff and Resident 1 (R1). Two out of two staff corroborated both allegations, and stated they did not recall the exact dates and times but stated R1 fell numerous times and at least one of those times required hospitalization. Per both staff, a re-appraisal of R1 due to falls was not done to their knowledge. R1 also corroborated both allegations and stated they fell multiple times, but did not recall exact dates and times. R1 stated that as a result of these falls they are no longer ambulatory. LPA reviewed facility progress notes for R1, which stated R1 sustained a fall on 6/10/22 at 6:30 a.m., 6/19/22 at 10:00 a.m., 6/20/22 at 12:10 p.m., 6/23/22 at 4:30 p.m., and on 6/28/22 R1 was sent to the hospital foRead the full finding— CDSS inspection report, November 15, 2023 · control 22-AS-20220629113139

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews and deliver findings for complaint allegations listed above. LPA Quiroz was greeted and met with Executive Director (ED) Rhonwinn "Rhon" Hipolito and discussed purpose of today's visit. The 10 day visit was conducted on 6/12/2023 by LPA Quiroz. During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff, residents and other witnesses. Regarding the allegation "Facility does not meet resident’s needs," the investigation revealed the following: Nine of ten interviewees denied the allegation. Six of six residents denied the allegation indicating staff respond timely when called for assistance. Resident 2 (R2) indicated "My room mate just wants to get rid of me and wants his own private room." CONTINUED ON NEXT PAGE... UnfoundedRead the full finding— CDSS inspection report, October 3, 2023 · control 22-AS-20230606092904

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings for the complaint received on 4/10/23. LPA De Perio explained the purpose of today's visit, was greeted, by Executive Director (ED) Rhonwinn Hipolito. It was alleged that staff did not ensure that resident's hygiene needs were met. During the physical plant of the facility, LPA observed residents to be clean and that hygiene needs were met. LPA reviewed documents such as the showering schedule and caregiver tasks. 9 interviews were conducted, which consisted of staff, residents, and external parties, of which interviews stated that if a resident refuses of wanting to shower that day, then staff will return the following day and attempt to assist resident with showering. 3 interviews conducted with residents verified that staff do assist with ensuring that hygiene needs are met. UnsubstantiatedRead the full finding— CDSS inspection report, June 20, 2023 · control 22-AS-20230410155851

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to follow up on Complaint investigation. During visit LPA met with Business Office Coordinator Chasidy Washington and Coordinator Elizabeth Mendoza. Ombudsman Joan Matheson was present and Administrator Rohn Hipolito was present via telephone. During investigation LPA toured facility, conducted interviews, and requested pertinent documents such as warning notice, copy of eviction notice and resident file. Regarding allegation Illegal Eviction, investigation revealed the following, Resident 1 and Resident 2 were issued final notice warnings dated 2/3/23 regarding disruptive verbal altercations with each other.Both parties were warned that further inappropriate behavior could lead to a 30 Day eviction notice. On 4/4/23, Resident 1 was issued a 30 day eviction notice for failure to follow house rules. Licensing Department granted approval for eviction notice. At this time facility has received court approval for UnlawRead the full finding— CDSS inspection report, June 12, 2023 · control 22-AS-20230120095133

Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation regarding the above allegations. LPA Velazquez gained entry into the facility and met with Medication Technician Anthony Sanchez and explained the purpose of the visit. LPA Velazquez spoke with Executive Director (ED) Rhon Hipolito on the phone to inform ED of the purpose of today's visit. On today's visit LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also requested copies of facility and resident records. During the course of the investigation the following was revealed. LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed copies of facility and resident records. The records reviewed included email communication between the facility and the Reporting Party (RP), Resident Preplacement Appraisal Information, Physician's Report, Resident (R) #1's Veterans Administration (VA) LonRead the full finding— CDSS inspection report, June 10, 2023 · control 22-AS-20230317144713

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA met with Executive Director Rhon Hipolito. LPA explained the reason for the visit. The investigation into the allegation, staff did not ensure resident's room was clean, revealed the following. It was alleged the Resident 1's (R1) room was not kept clean. Staff reported that all rooms are cleaned once a week and as needed if something is noticed by staff or reported by residents or their visitors. Staff interviewed reported that resident rooms are cleaned regularly but sometimes residents have accidents and they are cleaned as quickly as possible. LPA toured the facility and did not observe any rooms that were not clean. LPA toured R1's former room and observed it was clean. No evidence was provided that supports the allegation. Based on the evidence gathered the allegation, staff did not ensure residents roomRead the full finding— CDSS inspection report, May 25, 2023 · control 22-AS-20230518155233

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above for the purpose of delivering findings. LPA met with Administrator In Training (AIT) Rhon Hipolito and discussed the purpose of the visit. Complaint alleges resident's medication was not administered as prescribed, staff are not properly trained, staff do not answer facility phone, and facility is in disrepair. LPA interviewed two Medication Technicians and Wellness Director (WD) Kim Mims regarding allegation resident’s medication not administered as prescribed. Three out of three staff stated that the electronic Medication Administration Record (MAR) allows medication to be administered or checked as administered an hour before or an hour after the prescribed time. LPA reviewed Resident 1’s (R1’s) MARs for the month of July and August. On the MARs, there are administration times of 8 a.m., 9 a.m., 7 p.m., and 8 p.m. with staffRead the full finding— CDSS inspection report, December 14, 2022 · control 22-AS-20220802095010

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Administrator In Training (AIT) Rhon Hipolito and Wellness Director (WD) Kim Mims. LPA was taken on a guided tour of the inside and outside of the facility. Complaint alleges resident's call button is in disrepair. Interviews were conducted with former Executive Director (ED) Phat Nguyen, staff, and Reporting Party (RP). During interviews, RP stated the facility had no call button, just reception bells. ED Nguyen stated the call buttons are on a “piggyback system” and that a resident ripped theirs out of the wall, “so it took down the whole system.” In the meantime, the facility had given the residents silver desk bells. Staff 1 (S1), during their interview, stated that the light to room 326 was broken and could not be turned off. Therefore, staff "ignore" the light. (Cont. LIC 9099-C). SubstantiatedRead the full finding— CDSS inspection report, October 26, 2022 · control 22-AS-20220802095010

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. R1Read the full finding— CDSS inspection report, August 10, 2022 · control 22-AS-20210428152302

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 forRead the full finding— CDSS inspection report, August 10, 2022 · control 22-AS-20220103122410

Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to deliver the findings for the above complaint allegations. Upon arrival, LPA met with Wellness Director Kim Mims and Phat Nguyen. The investigation consisted of interviews with Administrator Mike Marion, staff, and residents as well as documentation from the facility. The following was determined: Administrator Mike Marion admitted to LPA that the dryers were non-operational on 12/2/20 and that they were repaired on 12/4/20. At that time, residents were instructed that laundry would be delayed as there was a backup. Mr. Marion stated that residents were told that they could take their laundry to a laundry mat if it was something urgent that needed washed. He stated that due to Covid there was a delay in having the dryers repaired. On 12/31/20, the cable at the building was nonoperational. Emails provided disclosed that two technicians came out to the facility on 1/2/21 and the issue was still not resolved. Due to tRead the full finding— CDSS inspection report, August 10, 2022 · control 22-AS-20210102174521

Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to deliver the findings for the above complaint allegation. Upon arrival, LPA met with Administrator Phat Nguyen. The investigation consisted of interviews with the Administrator, staff, and resident as well as documentation from the facility. The following was determined: R1 was admitted into the facility on 9/28/19. On 10/6/20 R1 reported that R2 grabbed R1’s buttocks on two different occasions while staff were walking R1 to the dining room for breakfast. R2 denied the allegations and staff interviewed also denied that the incidents took place. Based upon interviews and a review of records, the allegations above are unfounded, meaning the allegation is false, could not have happened or is without a reasonable basis. We have therefore dismissed the complaint allegation. An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Phat Nguyen. UnfoundedRead the full finding— CDSS inspection report, July 26, 2022 · control 22-AS-20201006092817

Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to deliver the findings for the above complaint allegations. Upon arrival, LPA met with Administrator Phat Nguyen. The investigation consisted of interviews with the Administrator, staff, and resident as well as documentation from the facility. The following was determined: R1 was admitted into the facility on 9/28/19. Records reviewed disclosed that R1 is non-ambulatory, has capacity for self care and stores and administers his own medications. The allegations allege that on 9/27/20, staff failed to escort R1 to breakfast. According to staff interviewed, R1 refused to go to breakfast. R1 administered himself his medications without food which caused R1 to faint and fall resulting in a cut on R1’s leg. When staff were later told of the incident staff did not administer first aid as R1 refused to be assessed for any injuries. Staff asked R1 if he would like go to the hospital or to the doctor's. R1 stated "no, I am goRead the full finding— CDSS inspection report, July 26, 2022 · control 22-AS-20200929093348

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit. LPA Quiroz was COVID-19 screened and greeted by front desk receptionist. LPA Quiroz met with Administrator Phat Nguyen identified herself and discussed the purpose of today's visit to deliver findings for the complaint allegations listed above. The initial 10-day tele visit was completed on 6/24/2020 via telephone due to COVID-19 precautionary measures. During the course of this investigation, LPA Quiroz conducted interviews, reviewed documents including but not limited Resident 1 (R1's) admission agreement, Resident Refund Request Summary dated 6/23/2020, Email from Administrator Jeff Gollihar dated 6/29/2020 at 9:51am and Main Place Senior Living Verification of Received/Reviewing Move-In Forms. It was alleged that "Responsible Party did not get a copy of admission agreement " and "Responsible Party did not receive a refund." During the course of this investigation, LPA Quiroz conducted inteRead the full finding— CDSS inspection report, July 13, 2022 · control 22-AS-20200615083228