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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004805
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:25:37 PM

Document Has Been Signed on 04/24/2023 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 VILLAFACILITY NUMBER:
306004805
ADMINISTRATOR:CHAVOSHPOUR, KAVEHFACILITY TYPE:
740
ADDRESS:18 SEQUOIA TREE LANETELEPHONE:
(949) 350-2338
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY: 6CENSUS: 4DATE:
04/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Facility Administrator - Zahrabigom FakhimTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit to follow-up on an incident report that was received on 4/20/23. LPA explained reason for visit, and was greeted by facility administrator (AD) Zahrabigom Fakhim, who also informed AD Kaveh Chavoshpour about visit.

On 4/20/23, the facility reported that a resident (R1), did not arrive to the facility after first day of day program.
LPA De Perio conducted an interview with AD Chavoshpour via phone call, who informed LPA about the incident. It was stated that R1 was scheduled to be dropped off at the facility by the OCTA bus by 2:30 PM on 4/19/23, however at around 4:00PM, R1 had not arrived to the facility, to which AD Chavoshpour contacted the day program social worker, who contacted R1's responsible party about the incident.

Day program social worker, then contacted R1's responsible party and 911, and both responsible party and police arrived to the facility prior to looking for the R1.

At 6:20PM, R1 returned to the facility and it was found that the OCTA bus dropped R1 off at the wrong location. Staff assessed R1 for any injuries and no injuries were noted.

LPA De Perio also reviewed the video footage obtained from the facility Ring camera, and observed R1 returning to facility at 6:20PM, with R1's responsible party and police present.

For today's visit, no citation 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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