<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 02/06/2023
Date Signed: 02/06/2023 03:24:28 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
02/03/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230203171639
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: 3DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Facility administrator-Parinaz "Naz" Safari,TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not transporting resident to medical appointments.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Celine De Perio made an unannounced 10-day visit to this facility for the complaint received on 2/3/2023 and to deliver the findings. LPA De Perio explained reason for visit and met with facility administrator (AD) Parinaz "Naz" Safari.

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)
Page: 1 of 2
Control Number 22-AS-20230203171639
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This agency has investigated the complaint alleging that facility is not transporting resident to medical appointments.

Per facility admission agreement, on page 2 under the section titled "Basic Services" it states "assistance in meeting necessary medication and dental needs as follows: assuring appointments are kept, arranging for transportation when necessary" . On page 7, section titled "Transportation" it states "Transportation arrangements to meet the health and dental needs of the resident. Resident financial responsibility. Facility will assist in arranging for transportation needs, facility will call for emergency vehicle when need arises, a planned activity program and transportation to participate in community events/activities, and listed transportation options such as OCTA ACCESS, TRIPS, Age Well Transportation", of which facility obtained a signature from the responsible party upon resident's admission acknowledging and consenting to this section. In addition, confirmation was received from the Assisted Living Waiver program director confirming that it was relayed to the resident's responsible party "that the facility is only responsible for ensuring that the resident gets to their appointments" reporting party also stated "I understand that it is not the facility's responsibility".

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 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: 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)
Page: 2 of 2