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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 03/27/2023
Date Signed: 03/27/2023 12:32:07 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
03/07/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230307083958
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:
03/27/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Facility Administrator- Kaveh ChavoshpourTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Facility failed to provide responsible party with information requested for resident's medical appointment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility for the complaint received on 3/7/2023 to deliver the findings. LPA De Perio explained reason for visit and met with facility administrator (AD) Kaveh Chavoshpour.

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

(SEE LIC9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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-20230307083958
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: 03/27/2023
NARRATIVE
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This department has investigated the complaint alleging that facility failed to provide responsible party with information requested for resident's medical appointment. LPA conducted record reviews and interviews which consisted of residents and staff. A total of 5 interviews were conducted, of which 2 of the interviews did not corroborate with the allegation, and 3 of the interviews were unable to be conducted due to unavailability. LPA reviewed the following documents but not limited to: the staff roster, the resident roster, the facility admission agreement, resident’s physician report, and additional forms of communication (via email) between the facility and responsible party. Per record review, on March 3, 2023, the facility provided resident’s responsible party with the following information: meal report, medication record and administration report, and sleep report. On March 6, 2023, the responsible party responded to the email and confirmed that the information provided was received. In the responsible party’s response, there were inquiries regarding meal times, to which the facility responded within an hour. Based on observations and review of documents 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 with AD Chavoshpour and a copy of this report was provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2