306004805-10-10-2023-22-AS-SSAS-CWL2NG-20231013173243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:18:27 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
08/15/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230815123016

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: 1	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	Staff on Duty-Soheila Amirmakky		TIME COMPLETED:	02:31 PM

ALLEGATION(S):

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Resident is being denied medical services

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty (S1) Soheila Amirmakky. Facility administrator (AD) Zahrabigom "Zahra" Fakim was unable to be present during time of visit, however provided consent for S1 to receive and sign report.

It was alleged that resident is being denied medical services. LPA De Perio conducted a total of 4 interviews that consisted of staff and residents, of which the 4 interviews did not corroborate with the allegation by stating that the facility does assist residents with medical services and does not deny a resident from obtaining medical services. Per record review, on 8/16/23, resident 1 (R1) was given an order for wheelchair due to R1 being a fall risk, however the order did not specify when to use the wheelchair. LPA De Perio interviewed R1 who verified that staff offer R1 to use the wheelchair, but R1 denies in wanting to use it. R1 stated "I don't need it, so why would I use it. I walk just fine".

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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-20230815123016

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: 10/10/2023

NARRATIVE

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During the tour of the facility, LPA De Perio observed that the wheelchair was located in R1's room and also observed that that R1 was ambulating independently around the facility.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, 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 evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with S1 Amirmakky and AD Fakim via phone call. A copy of this report was provided and explained.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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