306004805-2-6-2023-22-AS-LADS-CNWPZX-20230210104618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 02/06/2023
Date Signed: 02/06/2023 03:23:22 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230201090603

FACILITY NAME:	BLUE JASMINE VILLA		FACILITY NUMBER:	306004805
ADMINISTRATOR:	CHAVOSHPOUR, KAVEH		FACILITY TYPE:	740
ADDRESS:	18 SEQUOIA TREE LANE		TELEPHONE:	(949) 350-2338
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	6	CENSUS: 3	DATE:	02/06/2023
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Facility Administrator-Kaveh Chavoshpour		TIME COMPLETED:	02:21 PM

ALLEGATION(S):

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Facility staff refused to give resident medication as prescribed by resident's physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced 10-day visit to this facility for the complaint received on 2/1/2023 and to deliver the findings. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Kaveh Chavoshpour.

For today's visit, there are a total of 3 residents in care of which none are on hospice and 2 staff members on duty.

On today’s visit, LPA De Perio conducted file reviews, obtained pertinent documents, and conducted interviews.

(SEE LIC9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230201090603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VILLA	FACILITY NUMBER: 306004805
	VISIT DATE: 02/06/2023

NARRATIVE

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This agency has investigated the complaint alleging that facility staff refused to give resident medication as prescribed by resident's physician. Per documentation reviews and interviews, reporting party provided an email to AD stating that the resident's medication dosage was increased, however, in response, AD requested for a written note from the prescribing physician to confirm the medication increase prior to giving the resident the new dosage amount.

On 2/1/23, AD contacted the doctor to verify the increased dosage as stated by RP, and received confirmation from the doctor stating that the resident's medication was not changed as of 1/30/23.

Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with AD Chavoshpour and a copy of this report was provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

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