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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004805
Report Date: 11/23/2022
Date Signed: 11/23/2022 02:13:15 PM

Document Has Been Signed on 11/23/2022 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: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: 4DATE:
11/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Facility Administrator- Parinaz "Naz" SafariTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced case management visit at facility to follow up on Special Incident Report (SIR) regarding an incident that occurred on 11/4/22 between two residents. LPA De Perio was greeted and granted entry by facility administrator (AD) Parinaz "Naz" Safari who checked prior to entering facility. For this visit, there were a total of 4 residents in care, of which 0 are on hospice, and 1 staff on duty.

Per SIR, resident #1 (R1) got into an altercation with resident #2 (R2), when R1 grabbed R2's playing cards. R2 asked R1 to "nicely" leave her alone, and R1 responded with "shut up, don't tell me what to do". Upon staff attempting to de-escalate situation, R1 attempted to punch AD Safari. A total of 3 staff members were able to redirect R1, and no one was hurt.

LPA De Perio conducted file reviews on both residents and interviewed both residents.

LPA De Perio observed R1 in the living room watching television, and upon LPA De Perio inquiring how R1 was doing, R1 stated that she was doing "good". R1 was unable to continue with interview due to difficulty communicating.

LPA De Perio observed R2 was playing puzzles on the kitchen table. Upon inquiring to R2 about what occurred during incident, R2 stated "she (R1) was just having one of her behaviors again", but informed LPA De Perio that no one was hurt, and that there were no safety concerns. LPA De Perio inquired to R2 about the measures staff took to redirect R1, and R2 stated "they're good, they tell her to go to her room and she listens to them. They're always there to step in".

For today's visit, no deficiencies were issued, and no citations issued. LPA De Perio conducted an exit interview with AD Safari and a copy of this report was provided to the facility
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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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