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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:22:08 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
08/04/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230804130842
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:
11/07/2023
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Facility Administrator- Kaveh ChavoshpourTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff installed a blue light in the resident's room that is interfering with the resident's sleep.
Staff did not seek consent from resident's POA or medical team to install a blue light in the resident's room.
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 facility administrator (AD) Kaveh Chavoshpour.

It was alleged that staff installed a blue light in the resident's room that is interfering with the resident's sleep. Per documentation review, LPA observed that resident 1 (R1) did have a blue light installed in the room, however upon LPA conducting an interview with R1, R1 stated "I like it" and when asked about sleep interference, R1 stated "I sleep very good" and denied of any interference with sleep.

It was alleged that staff did not seek consent from resident's POA or medical team to install a blue light in the resident's room. Per documentation review and observation, it was observed that R1 had a blue light in the room but the color of the light was randomly chosen due to R1 having a light in the room that had multiple colors.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
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 4
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
08/04/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230804130842

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:
11/07/2023
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Facility Administrator- Kaveh ChavoshpourTIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not allow resident to have visitors.
INVESTIGATION FINDINGS:
1
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3
4
5
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13
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 facility administrator (AD) Kaveh Chavoshpour.

It was alleged that staff did not allow resident to have visitors. LPA reviewed the videos of the external Ring camera footage, of which did not show staff denying visitors. LPA reviewed the admission agreement for R1, and observed that the POA of R1 had acknowledged and signed the admission agreement visitation section, adhering to the visitation hours of the facility which was from 10:00AM to 6:00PM. LPA observed that AD informed R1's visitors that if needed to visit outside of those hours, to coordinate prior to visitation to ensure remainder of the residents within the facility were not disturbed.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20230804130842
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: 11/07/2023
NARRATIVE
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Based on LPA’s interviews which were conducted, review of documents obtained, and observations, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with AD Chavoshpour.

A copy of this report was provided and explained.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20230804130842
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: 11/07/2023
NARRATIVE
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 R1's POA then expressed concerns regarding the light, therefore, R1's nurse suggested for the facility to not utilize a blue light to which then the facility changed the light to a different color instead, and did not continue to use the blue light.

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 AD Chavoshpour.

A copy of this report was provided and explained.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4