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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004805
Report Date: 08/01/2022
Date Signed: 08/01/2022 11:37:50 AM

Document Has Been Signed on 08/01/2022 11:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BLUE JASMINE VILLAFACILITY NUMBER:
306004805
ADMINISTRATOR:CHAVOSHPOUR, KAVEHFACILITY TYPE:
740
ADDRESS:18 SEQUOIA TREE LANETELEPHONE:
(949) 350-2338
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY: 6CENSUS: 2DATE:
08/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator- Parinaz "Naz" SafariTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced Case Management visit to facility. LPA De Perio was greeted by facility administrator (AD) Parinaz "Naz" Safari who took temperature prior to entering facility and verified that there are no active COVID cases as of 8/1/22. AD Safari also contacted AD Kaveh Chavoshpour to notify him about visit and communicated with LPA De Perio via phone call. Currently, there are a total of 2 residents in care, of which none are on hospice. LPA De Perio observed AD certificate for Parinaz Safari which expires on 1/20/24 and Kaveh Chavoshpour which expires on 3/6/23.

The purpose of this Case Management visit was to follow up on a call LPA De Perio received from Ombudsman Lynette Fugitani in regards to a concern of a locked gate blocking the main entrance front door of the facility and not being able to access the main doorbell. Upon arrival, LPA De Perio observed a gate with a numerical code lock, and a Ring doorbell with a camera which was operational and functional. LPA De Perio was informed by AD Safari that the main facility door is not locked due to residents wanting to walk outside, and that instead, the gate is used as the "main door". Based on LPA De Perio's observation, this incident has been cleared and resolved,

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.
No citations were issued.

LPA De Perio advised AD Safari and AD Chavoshpour to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Safari and AD Chavoshpour via phone and a copy of this report was provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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