<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 04/10/2023
Date Signed: 04/10/2023 03:03:45 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
02/22/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230222123029
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:
04/10/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Facility administrator-Parinaz "Naz" SafariTIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide care and supervision to resident(s) during the night.
Staff are not ensuring that resident's toileting needs are being met while in care.
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 for the complaint received on 2/22/2023 to deliver the findings. LPA De Perio explained reason for visit and met with facility administrator (AD) Parinaz "Naz" Safari.

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: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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-20230222123029
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: 04/10/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This department has investigated the complaint alleging that staff do not provide care and supervision to resident(s) during the night. LPA conducted record reviews and interviews which consisted of 2 staff and 4 residents. LPA reviewed the following documents such as but not limited to: the resident roster, staff roster, staff schedule, the facility admission agreement, the resident’s physician report, and further documents regarding supervision at night such as the nightly bathroom log. LPA also conducted a total of 6 interviews of which 1 interview was unable to be conducted due to unavailability, and the remainder of the 5 interviews did not corroborate with the allegations due to reporting that the facility staff provides each resident with a call button to utilize to notify staff if assistance is needed. 1 of the interviews also added that the staff present at night will check on residents a minimum of twice a night. When LPA conducted a tour of the facility, LPA tested all the resident call buttons and observed that all buttons were functional and operational, and that once the button was pressed, an alarm will sound throughout the facility to notify staff. 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.

This department has investigated the complaint alleging that staff are not ensuring that resident's toileting needs are being met while in care. LPA conducted record reviews and interviews which consisted of 2 staff and 4 residents. LPA conducted a total of 6 interviews, of which 1 interview was unable to be conducted due to unavailability, and 5 of the remaining interviews did not corroborate with the allegation. LPA reviewed the following documents such as but not limited to: the resident roster, staff roster, staff schedule, the facility admission agreement, receipts of toiletry supplies, bathroom log from August 2022-February 2022, and the resident’s physician report. LPA also conducted a tour of the interior portion of the facility and observed that the facility had an adequate supply of toiletry supplies (such as: diapers and pads), which is located inside the facility and in the garage. 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.

For this visit, no citations were issued.

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: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2