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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:40:14 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
03/08/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230308160812
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:
05/04/2023
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Facility administrator- Kaveh ChavoshpourTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Licensee/Administrator is harassing the resident about paying more money for rent.
Licensee/Administrator is entering the residents room without permission requesting the resident pay more rent money.
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 3/8/2023 to deliver the findings. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Kaveh Chavoshpour.

It was alleged that licensee/administrator is harassing the resident about paying more money for rent. LPA De Perio conducted a total of 3 interviews that consisted on staff and residents. LPA was unable to conduct an additional 3 interviews due to unavailability. 3 out of the 3 interviews conducted did not corroborate with the allegation. 1 out of the 3 interviews conducted also denied of ever witnessing or hearing any forms of harassment take place. Per record review, it was found that resident (R1) is behind on the monthly fees due, and gets upset when the topic of needing to pay is brought up. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
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-20230308160812
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: 05/04/2023
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

It was alleged that licensee/administrator is entering the resident’s room without permission requesting the resident pay more rent money. LPA De Perio conducted a total of 3 interviews that consisted on staff and residents. LPA was unable to conduct an additional 3 interviews due to unavailability. 3 out of the 3 interviews conducted did not corroborate with the allegation. 1 out of the 3 interviews conducted, shares a room with R1, who stated that staff "are respectful of our space”. LPA De Perio conducted record reviews of regarding R1. Based on the information gathered during the investigation and review of documents obtained, LPA 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 the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

For today's visit, no citations were issued.

An exit interview was conducted with AD Chavoshpour 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: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2