306004805-8-10-2023-22-AS-AORZ-CUTRGP-20230818130103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 08/09/2023
Date Signed: 08/10/2023 03:06:07 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
07/26/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20230726155846

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: 2	DATE:	08/09/2023
		UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Naz Safari		TIME COMPLETED:	03:22 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff restricted ombudsman representative's right to conduct a proper facility visit

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Administrator Naz Safari and explained the reason for the visit.

During the course of the investigation, LPA toured the facility and interviewed staff, resident, and witnesses. Regarding the allegation that staff restricted ombudsman representative's right to conduct a proper facility visit, the investigation revealed the following: On 07/25/2023, witness attempted to visit at the facility. Facility staff informed verbally that the visit would be recorded. LPA observed a sign at the entrance gate stating that visitors are on camera. Visitor did not want to be recorded and declined to come in the facility. Facility staff deny restricting the visit stating they only advised of recording. Therefore the allegations are deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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 3