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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 02:12:04 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
01/25/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230125162114
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:
01:31 PM
MET WITH:Facility Administrators- Kaveh Chavoshpour and Parinaz “Naz” SafariTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not provide requested medical information to resident's responsible party in a timely manner.
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 1/25/23 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 2
Control Number 22-AS-20230125162114
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 did not provide requested medical information to resident's responsible party in a timely manner. LPA 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, residents, responsible parties and Ombudsman. LPA conducted a total of 8 interviews of which 1 was unable to be interviewed due to unavailability, 3 out of the 8 interviews corroborated with the allegation, 4 out of the 8 did not provide further information regarding the allegation. On 1/8/23, the facility administrator sent the responsible party the requested documentation specifically regarding the resident’s medication record and medical information. In addition, the administrator provided the requested documentation to the responsible party in person, via text, faxed it to the resident’s preferred doctor twice and gave copies to the Ombudsman. On 12/16/22 facility’s Ring camera recorded via video footage that both the Ombudsman and responsible party obtained copies of the requested medical information from the administrator. On 1/23/23, the responsible party requested that the administrator send the same resident’s medical information by 1/25/23 by 10 AM. On 1/25/23, the administrator reminded the responsible party via email that the requested information and documents were emailed on 1/12/23; nonetheless, he provided the requested documentation again for the responsible party’s reference. On 1/1/23 and 1/24/23, the administrator also sent the responsible party the resident’s weekly report and medication log, per request of responsible party. Based on the interviews conducted and documentation obtained, the Department has found that the complaint is 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 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 2