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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 09/09/2021
Date Signed: 10/11/2021 07:51:04 AM

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
10/09/2020 and conducted by Evaluator Shobhana Frank
COMPLAINT CONTROL NUMBER: 22-AS-20201009131947
FACILITY NAME:IRIS GUEST HOMEFACILITY NUMBER:
306005722
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2702 N BERKELY STTELEPHONE:
(714) 507-8040
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 5DATE:
09/09/2021
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Licensee Brevet DaoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff failed to access resident for injuries.
Facility staff were not aware of resident's whereabouts on multiple occasions.
Resident AWOL from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to deliver findings on the above allegation. LPA Frank met with Administrator Brevet Dao and explained the reason for the visit.

During the course of the inves5tigation, LPA interviewed staff as well as reviewed and obtained pertinent documentation such as Physician’s Report dated 09/16/20, Admission Agreement dated 9/16/20, Vitas Hospice care Medication list dated 10/01/20, Doctor’s note dated 10/7/21, Vitas Hospice Care visit list, LPA interviewed Staff 1 (S1) Staff 2 (S2) Resident 1 and Vitas nurse.
Investigation into allegation Facility staff failed to access resident for injuries is unfounded.
Based on interview and reviews of Physician’s report dated 9/16/21 R 1 had imbalance of gate. On 10/8/20 she (R1) was outside on patio she fall and scratch her knee. Licensee and Vitas care hospice nurse observed the incident and Vitas nurse provided first aid to R1. R 1 had bruises on both her knees and a swollen right ankle Next day licensee checked her knees and it was bruised. R1 did not complaint having any pain or discomfort.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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-20201009131947
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: IRIS GUEST HOME
FACILITY NUMBER: 306005722
VISIT DATE: 09/09/2021
NARRATIVE
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Investigation into allegation Facility staff were not aware of resident's whereabouts on multiple occasions is unfounded.
Based on interview of R1, S1 and S 2. S 1 reported that yes, on 10/7/20 only one time R 1 went out to the store. He went right away and bring her back to the facility. After the incident licensee requested Doctor’s note indicates that R 1 not to leave the facility unassisted.
Investigation into allegation Resident AWOL from the facility is unfounded.
Based on the interview of S1, S 2 and R1. R1 reported that She loves to sit by her patio area or side of the home and read her Christian book, drink coffee and smoke as permitted. She After 10/7/20 (R1) did not AWOL from the facility.
This agency has investigated the complaint and is determined to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegations of Facility staff failed to access resident for injuries, Facility staff were not aware of resident's whereabouts on multiple occasions and Resident AWOL from the facility were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2