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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:03:17 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
12/13/2022 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221213143447
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:
03/16/2023
UNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Facility Administrators - Kaveh Chavoshpour and Parinaz “Naz” SafariTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is unsanitary.
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 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 12/13/22 against this facility.

For today’s visit, there are a total of 4 residents in care of which 1 is on hospice.
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: 1 of 5
Control Number 22-AS-20221213143447
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 unsanitary. LPA De Perio conducted record reviews and interviews, of which all interviews conducted reported that facility is clean, and 1 interview specifically shared “they are cleaning all the time”. LPA conducted a total of 7 interviews with staff, residents, and the Ombudsman, of which 7 out of the 7 interviews conducted reported that the facility is clean. LPA De Perio also conducted a tour of interior portion of the facility and observed that all bedrooms had furniture in good condition and no odors. On 12/11/22, a welfare check was conducted by Irvine Police department, and per police report, it indicated that the resident was clean and happy. During the visit conducted on 12/20/22, LPA De Perio was also notified by staff that when a resident has an accident, one staff member will clean the resident, and the other staff member will clean the area where the accident took place. On 2/9/23, the assigned care coordinator from the Assisted Living Waiver program was instructed to check on the resident, of which the care coordinator stated that the resident was also observed to be clean and happy. 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 and 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: 2 of 5
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
12/13/2022 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221213143447

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:
03/16/2023
UNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Facility Administrators - Kaveh Chavoshpour and Parinaz “Naz” SafariTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not allowing resident's to have visitors.
Resident missed 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 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 12/13/22 against this facility.

For today’s visit, there are a total of 4 residents in care of which 1 is on hospice.
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: 3 of 5
Control Number 22-AS-20221213143447
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 allowing residents to have visitors. LPA conducted record reviews and interviews with staff, residents, resident’s responsible party and Ombudsman. LPA conducted a total of 7 interviews with staff and residents, and 5 out of the 7 interviews stated that facility has not actually denied visitors, and the 2 remaining interviews did not corroborate with the allegation due unavailability and having no knowledge in relation to the allegation. On 12/9/22, facility administrator issued reporting party a “Visiting Notice” stating that reporting party was not allowed to visit due to violating the facility’s visiting policy through interactions and behaviors with residents and staff, which was described as “harassment”. Upon administrator consulting with the Department after visitation notice was issued, the Department disclosed that the facility is unable to deny visitation, therefore, facility administrator issued a revised notice on 12/28/22 stating that facility staff is able to request for a visitor to leave the premises if the facility visitation policies are being violated. During the time frame of 12/9/22-12/28/22, facility verified that visitors were not denied, and per reporting party, it was also stated that the facility did not actually deny visitation, despite visitation notice being issued. 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.
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 5
Control Number 22-AS-20221213143447
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
1
2
3
4
5
6
7
8
9
10
11
12
13
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15
16
17
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The Department has investigated the complaint alleging that resident missed medical appointments. LPA De Perio conducted file reviews and interviews with residents, and staff, and it was reported that residents have their family take them to their appointments or are able to independently attend appointments on their own. On 12/20/22, per facility, the responsible party had scheduled an appointment on behalf of the resident, however, did not show up to pick the resident up. On 12/27/22, the reporting party stated that the facility is still “denying” taking the resident to appointments, of which on 1/23/22, the facility reiterated to responsible party that they are unable to do so due to the residents behaviors. In addition, per facility admission agreement, it states that the facility will take measures to ensure that the resident will keep all medical and dental appointments. LPA conducted a total of 6 interviews, and 3 out of the 6 interviews conducted denied that any appointments were missed, and the 3 remaining interviews did not corroborate with the allegation due unavailability and having no knowledge in relation to the allegation. In addition, the facility agreement also states that the facility will assist in arranging outside transportation to ensure that appointments are kept, and the remaining 3 interviews did not with the allegation due to either not having knowledge in relation to the allegation, or due to unavailability. The facility also expressed that if a resident is exhibiting physical behaviors that are “dangerous” (such as: kicking, punching, pushing), then the facility will inform the resident’s responsible party in order to coordinate ways and agree on a plan, to ensure that the resident is able to attend the appointment. 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 and a copy of this reported 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: 5 of 5