306004805-7-21-2023-22-AS-SSAS-CU42ZP-20230725175040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:46:02 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
06/14/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230614135946

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:	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Kaveh Chavoshpour, Administrator Parinaz Safari, Administrator		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to deliver findings into the investigation of the allegation listed above. LPA was greeted and granted entry by administrator Parinaz Safari after introducing himself and stating the purpose of the visit. Administrator Kaveh Chavoshpour was notified of the findings via telephone.

An initial complaint investigation visit was led on June 19, 2023. LPA accompanied by caregiver conducted a tour of the physical plant. Resident records for the three residents in care requested, obtained and reviewed during the visit. Hospital records requested and obtained from Hoag Hospital Irvine.
It is alleged that resident R1 sustained a head injury due to a fall at the facility on June 14, 2023. Paramedics were called to the facility and transferred the resident to the Emergency Department at Hoag Hospital in Irvine for evaluation. Resident received a CT scan and was discharged to the facility later the same evening.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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-20230614135946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLUE JASMINE VILLA	FACILITY NUMBER: 306004805
	VISIT DATE: 07/21/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

Hospital discharge notes reviewed indicate: "6/14/2023 11:51 PM PDT The patient's condition did not warrant admission to the hospital. Patient is clinically stable, the emergency department evaluation does not indicate that they are in danger of imminent deterioration, and deemed safe for outpatient management." No mention is made of a concussion diagnosis at that time.

An incident report submitted by the facility indicates that the injury was sustained while the resident was attending an adult day care program. Declarations gathered at bedside in the Emergency Department are inconsistent and place the incident both at the residential care facility and at the adult day care program. Video footage from the morning of the day the incident occurred do not allow to corroborate the presence of facial bruising upon departure from Blue Jasmine Villa that morning.

As a result, the allegation listed above is deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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