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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:20:02 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
08/16/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230816091158
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: 1DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Staff on Duty-Soheila AmirmakkyTIME COMPLETED:
03:46 PM
ALLEGATION(S):
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Staff did not assist resident with prescribed medications.
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 staff did not assist resident with prescribed medications. 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 staff does assist residents with prescribed medications. 2 of the interviews conducted with residents stated that staff help "all the time". Per record review, LPA observed that facility documents when medications are given to a resident, along with updating the residents medication chart when the residents doctor prescribes new medication.
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)
Page: 1 of 2
Control Number 22-AS-20230816091158
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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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)
Page: 2 of 2