<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 11/19/2025
Date Signed: 11/19/2025 08:23:31 AM

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
07/25/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230725154002
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: 2DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Kaveh ChavoshpourTIME COMPLETED:
08:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident in care sustained unexplained injuries
Staff handled resident in a rough manner
Staff spoke inappropriately to resident in care
Staff did not follow proper reporting requirements
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 allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and clients. Regarding the allegations that resident in care sustained unexplained injuries, staff handled resident in a rough manner, staff spoke inappropriately to resident in care and staff did not follow proper reporting requirements, the investigation revealed the following: Per interviews conducted with facility staff, Resident 1 (R1) did not receive a head injury while at the facility. Resident had returned from the day program when responsible party called 911 to assess bruising on the resident's head. Facility Administrator states paramedics deemed the resident cleared but responsible party requested transfer to Hoag Hospital Irvine. 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." CONT ON LIC 9099C DATED 11/19/2025
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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-20230725154002
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: 11/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
No mention is made of a concussion diagnosis at that time. Incident report dated 06/14/2023 indicated resident returned from day program with a bruised eye lid. Incident report stated responsible party was notified about the bruising after day care. Facility staff denies knowledge of a bruised hand. LPA observed video surveillance from 06/12/2023 showing staff holding onto R1's arm as family member takes the resident out. LPA did not observe any abuse or aggression on video and two out of two staff and two out of two residents deny any verbal or physical aggression from staff.
Based on observation, record review and interviews, LPA is unable to corroborate the allegations. Therefore the allegations are deemed 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. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2