306004805-4-24-2023-22-AS-SSAS-CS4VCV-20230523161947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:24:32 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
04/14/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230414151941

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:	04/24/2023
		UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Facility Administrator - Zahrabigom Fakhim		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility has not provided POA with requested documentation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced 10-day visit to this facility for the complaint received on 4/14/2023 and to deliver the findings. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Zahrabigom Fakhim.

For today's visit, there are a total of 4 residents in care of which 1 is on hospice and 2 staff members on duty.

On today’s visit, LPA De Perio conducted file reviews, obtained pertinent documents, and conducted interviews.

This department has investigated the complaint alleging that facility has not provided POA with requested documentation.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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-20230414151941

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: 04/24/2023

NARRATIVE

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LPA conducted an interview and reviewed documents which consisted of the following but not limited to: the facility admission agreement, and email exchanges directly from the reporting party (RP) and staff.

On 4/14/23, RP requested for invoices copies from the facility, of which AD did not deny in providing, and stated that documents requested will be sent to RP on 4/17/23.

On 4/17/23, AD provided RP with the invoices, payment receipts and itemized lists dated from 7/26/22-4/30/23 per RP request, of which RP acknowledged and confirmed on 4/19/23.

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 today's visit, no citations were issued.

An exit interview was conducted with AD Fakhim and AD Chavoshpour (via phone call) and a copy of this report was explained and provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

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