306004805-3-16-2023-22-AS-LADS-CQ4RFC-20230320125852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 03/16/2023
Date Signed: 03/16/2023 01:56:09 PM

Substantiated

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
12/06/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221206134752

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: 4	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Facility Administrators - Kaveh Chavoshpour and Parinaz “Naz” Safari		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Resident's medication was changed without authorization
Facility failed to seek medical attention
Unlawful eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrators, Kaveh Chavoshpour and Parinaz “Naz” Safari and stated the purpose of this visit which was to deliver the final findings for the complaint received on 12/6/22 against this facility.

For today’s visit, there are a total of 4 residents in care of which 1 is on hospice.

(SEE LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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 10

Control Number 22-AS-20221206134752

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: 03/16/2023

NARRATIVE

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The Department has investigated the complaint alleging that resident’s medication was changed without authorization. During the course of the investigation, LPA De Perio conducted interviews with staff, residents as well as record reviews such as, but not limited to: resident’s physician report, medication log dated from November 2022-Janruary 2022, facility admission agreement, incident reports, communication between the facility, responsible party and medical providers. Initially, it appeared that that the facility staff were following the prescribed medications per physician orders, as was indicated on the resident’s centrally stored medication log. However, upon further review, it was determined that on one occasion, the resident’s responsible party and facility administrator were in communication, and the facility administrator informed the responsible party that the medication (Depakote) was being decreased, but there were no official orders for this change from the prescribing physician. LPA conducted a total of 6 interviews of which 3 of the interviews did not corroborate with the allegation due to the individuals not having any knowledge about medication changes and authorizations. 1 interview was unable to be conducted due to unavailability, and 1 interview corroborate with the allegation. Based on the LPA’s investigation, which consisted of interviews and record reviews the Department has found that the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

The Department has investigated the complaint alleging that the facility failed to seek medical attention for resident #1 (R1). LPA De Perio conducted interviews with facility staff and residents. LPA conducted a total of 6 interviews, of which 4 out of the 6 interviews stated that the facility does contact 911 if medical attention is needed, and the 2 remaining interviews did not corroborate with the allegation due unavailability and having no knowledge in relation to the allegation. In this particular case, however, R1’s responsible party observed an injury on R1’s head and proceeded to inquire why the facility staff did not seek medical attention for R1. The facility administrator replied to R1’s responsible party that 911 was not contacted due to the injury being “just a scratch”. LPA reviewed the picture of R1’s injury and observed a raised, bruised bump on R1’s forehead above R1’s left eye with a scratch, which required medical attention. Based on the information gathered through the course of the investigation, the Department has found that the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 10

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
12/06/2022 and conducted by Evaluator Celine DePerio

COMPLAINT CONTROL NUMBER: 22-AS-20221206134752

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: 4	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Facility Administrators- Kaveh Chavoshpour and Parinaz “Naz” Safari		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Facility failed to report incidents to responsible party
Facility falsified documents

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 10

Control Number 22-AS-20221206134752

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: 03/16/2023

NARRATIVE

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The Department has investigated the complaint alleging that facility failed to report incidents to R1’s responsible party. LPA De Perio conducted record reviews such as, but not limited to: resident’s physician report, facility admission agreement, incident reports, communication between the facility, responsible party and medical providers, and interviews with staff, residents, and residents’ responsible parties, and found that the facility keeps in contact with responsible parties via text message and verbal conversation and will notify the resident’s responsible party with changes of condition, behaviors and incidents. LPA conducted interviews with residents’ responsible parties, it was stated that the facility staff will inform them of any incidents either verbally or via text message. LPA conducted a total of 8 interviews which consisted of staff, residents and responsible parties. 1 out of the 8 interviews were unable to be conducted due unavailability, 4 out of the 8 interviews did not corroborate with the allegation, and 3 out of the 8 interviews verified that facility does report incidents to the responsible party. to One responsible party stated, “every time there was an update, they told me right away". The reporting party is stating that incidents were not reported to the responsible party, however, according to emails between the facility and responsible party, incidents were reported via email, text message and in person. Based on interviews and review of records 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.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 10

Control Number 22-AS-20221206134752

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: 03/16/2023

NARRATIVE

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The Department has investigated the complaint alleging that facility falsified documents. During a visit initiated on 12/12/22, LPA De Perio conducted record reviews such as, but not limited to: resident’s physician report, medication log, facility admission agreement, incident reports, communication between the facility, responsible party and medical providers, and interviews with staff and residents, and any other individual specified on the indicated incident reports. LPA conducted a total of 6 interviews of which 1 interview was unable to be conducted due to unavailability, 3 out of the 8 did not corroborate with the allegation, and 2 out of the 8 interviews did corroborate. 1 of the interviews that corroborated with the allegation described the incident that occurred as reported on the incident reports the facility provided Community Care Licensing. Per record review, the facility has submitted incident reports regarding altercations that have occurred in the facility involving R1. The interviews conducted stated that R1 has behaviors and provided information regarding how staff handle the situation and de-escalate. During this visit, LPA De Perio also observed R1 having an allegation, yelling and getting close to resident 2’s (R2) face. R1 was quickly redirected by staff. Facility has also submitted incident reports to the Department between the time frames of 12/1/22-1/25/23. If there was another resident involved, LPA conducted interviews that corroborated with the reports that were submitted to the Department. Based on interviews and review of records 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 a copy of this report and Appeal Rights were provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 10

Control Number 22-AS-20221206134752

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: 03/16/2023

NARRATIVE

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The Department has investigated the complaint alleging that facility issued an unlawful eviction. LPA conducted record reviews, such as, but not limited to incident reports, communication between the facility and responsible party, medical documents, eviction notices and interviews with staff, resident’s responsible party, and Ombudsman. On 12/6/22, the facility administrator (AD) issued resident and resident’s responsible party a 3-day eviction prior to notifying Licensing agency. On 12/7/22, AD rescinded the 3-day eviction notice and provided the resident and resident’s responsible party an official 30-day eviction notice on 12/28/22. On 2/3/23, the facility issued a 60-day eviction. Based on the LPA’s investigation, which consisted of interviews and record reviews the Department has found that the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

For today's visit, citations were issued per Title 22 California Code of Regulations.

An exit interview was conducted with both AD's and a copy of this report, annd Appeal Rights were provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 10

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
12/06/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221206134752

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: 4	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Facility Administrators - Kaveh Chavoshpour and Parinaz “Naz” Safari		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Facility not following physician orders

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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

LIC9099 (FAS) - (06/04)

Page: 7 of 10

Control Number 22-AS-20221206134752

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: 03/16/2023

NARRATIVE

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The Department has investigated the complaint alleging that facility is not following physician orders. LPA De Perio conducted record reviews such as, but not limited to resident’s physician report, medication log facility admission agreement, incident reports, communication between the facility, responsible party, medical providers and interviews with staff and residents. LPA conducted 6 interviews of which 2 of the interviews stated that the facility does follow physician orders, and the remaining 4 interviews did not provide any further information due to difficulty understanding or unable to answer. According to the allegation, the facility is not following physician orders as the facility was not ensuring that the wrist brace given to the resident, was worn at all times. Per record review of the doctor’s order, on 12/2/22, the resident attended an appointment for a wrist exam. On 12/5/22, the responsible party informed the facility via text message that the wrist brace must be kept on the resident. Per doctors note received on 12/28/22, it stated that the wrist brace was advised to use if the resident was experiencing any pain. LPA De Perio conducted an interview with the resident on 12/12/22, who freely moved her wrist and stated, “this feels good” and also reported that there was a wrist brace, but “did not need it”. LPA De Perio also conducted a tour of the resident’s room and observed a wrist brace in the room. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED

An exit interview was conducted a copy of this report was provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 10

Control Number 22-AS-20221206134752

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/16/2023 Section Cited CCR 87224(c)	1 2 3 4 5 6 7	87224 Eviction Procedures (c) The licensee shall...seeking approval from the Department... This requirement was not met as evidence by:	1 2 3 4 5 6 7	As POC, licensee will send assigned LPA proof of understanding regarding the regulation cited on or by 3/20/23.
	8 9 10 11 12 13 14	Licensee issued a 3-day eviction to the resident and rseponsible party on 12/6/22, and recinded it on 12/7/23. Threat reduced. This can pose a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 9 of 10

Control Number 22-AS-20221206134752

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/16/2023 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (e) For every prescription... there shall be a signed, dated written order from a physician... This requirement is not met as evidence by:	1 2 3 4 5 6 7	As POC, licensee will provide assigned LPA with proof of understanding of the regulation cited on or by 3/20/23.
	8 9 10 11 12 13 14	Based on LPAs observations, record reviews and interviews, licensee failed to obtain a dated, written order from a physican. This can pose an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 03/16/2023 Section Cited CCR 87211(a)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:	1 2 3 4 5 6 7	As POC, licensee will provide assigned LPA with proof of understanding of the regulation cited on or by 3/20/23.
	8 9 10 11 12 13 14	Based on LPAs observations, record reviews and interviews, licensee failed to report resident's injury to licesning agency. This can pose an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 10 of 10