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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 01:54:39 PM

Unsubstantiated


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 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:
01:21 PM
MET WITH:Kaveh ChavoshpourTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility failed to advise primary care physician of change in medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit on January 6, 2023 to investigate the complaint allegation 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 advise primary care physician of change in medications

During the investigation, LPA Haley discovered R4 was seeing multiple medical professionals/primary care physicians
Continued on LIC9099C
Unsubstantiated
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)
Page: 1 of 2
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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LPA Haley received copies of text messages sent October 23, 2022 that confirm R4’s responsible party was made aware of an increase in R4’s medication. Additionally, LPA Haley received a screen shot of a message that was sent from R4’s responsible party to the licensee regarding a decrease in one of R4’s medications. Further, after reviewing numerous text exchanges between R4’s Responsible Party and the Licensee, it was determined that R4’s responsible party provided instructions and attempted to provide direction/coordination regarding prescriptions/dosages between R4’s psychiatrists, neurologist, and physician who were all treating R4 as evidenced by text messages sent October 23, 2022 and November 10, 2022.

Based on the information gathered during the investigation, review of all documents obtained, the Department 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 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 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)
Page: 2 of 2