306004805-3-16-2023-22-AS-LADS-CQBKSN-20230327080950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 03/16/2023
Date Signed: 03/16/2023 01:52:47 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
12/28/2022 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221228143511

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:	12:45 PM
MET WITH:	Kaveh Chavoshpour		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility failed to respect resident's personal right to chose physician
Facility is retaliating against resident for complaining

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit on January 6, 2023 to investigate the complaint allegations listed above. During the initial visit LPA Haley conducted interviews with the facility Licensee/Administrator, House Manager/Caregiver Staff 1 (S1), Staff 2 (S2), Resident 1 (R1), and Resident 2 (R2). LPA Halley conducted a second unannounced visit to compete resident interviews and gather additional information. During the second visit, LPA Haley interviewed, the Licensee/Administrator for a second time, Resident 3 (R3) and Resident 4 (R4). Further, LPA Haley conducted a telephone interview with Resident 4's (R4) Responsible Party.

Regarding the allegation, Facility failed to respect resident's personal right to choose physician

During the initial unannounced visit LPA Haley conducted five interviews (3 Staff, 2 residents) and no staff or resident could corroborate the allegations above.
Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
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)

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Control Number 22-AS-20221228143511

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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Further, LPA Haley was provided with text message documentation between the Licensee and R4’s Responsible Party regarding R4’s physician. With the change in physician in question, it was clear from the text messages dated August 15, 2022, August 23, 2022, and August 31, 2022 the responsible party was in agreement to allow R4 to be seen and treated by Blue Jasmine Villa’s facility physician. It is unclear if Blue Jasmin Villa’s in-house physician was ever designated as the only physician to see R4; however, it was clear R4’s responsible party was aware R4 was being seen by the in-house physician, in communication with the facility in-house physician, and asked if the in-house physician could treat R4 for what appeared to be a “foot fungus on R4’s foot.” It is unclear from the text messages provided if R4 was treated for the foot fungus or not. Per the licensee, the in-house physician sent a nurse out to the facility and the “fungus” was treated with a cream.

Based on the information gathered during the investigation, observation, and review of all documents obtained, the following allegation: Facility failed to respect resident's personal right to choose physician, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

Regarding the allegation, Facility is retaliating against resident for complaining

During the investigation, six interviews were conducted with Staff and Residents (3 Staff, 3 Residents) and 1 more attempted resident interview with R4, all of which did not or could not corroborate the allegation above. LPA Haley discovered R4 has not been retaliated on in anyway. Furthermore, R4 has not made a single complaint against Blue Jasmine Villa.

Based on the information gathered during the investigation, observation, and review of all documents obtained, the following allegation: Facility is retaliating against resident for complaining, is deemed Unfounded, meaning the allegation is 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.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
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)

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