306005722-10-11-2021-22-AS-MSTC-C7Q2VD-20211011174347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 09/09/2021
Date Signed: 10/11/2021 07:52:39 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
09/21/2020 and conducted by Evaluator Shobhana Frank

COMPLAINT CONTROL NUMBER: 22-AS-20200921101517

FACILITY NAME:	IRIS GUEST HOME		FACILITY NUMBER:	306005722
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	2702 N BERKELY ST		TELEPHONE:	(714) 507-8040
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 5	DATE:	09/09/2021
		UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Licensee Brevet Dao		TIME COMPLETED:	02:34 PM

ALLEGATION(S):

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Facility staff left resident in soiled clothing for an extended period of time.
Facility staff do not assist resident with transfers out of bed.
Facility staff are not providing resident with an adequate quality and quantity of food.

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 Licensee Brevet Dao and explained the reason for the visit.

During the course of the investigation, LPA interviewed staff as well as reviewed and obtained pertinent documentation such as Physician’s Report dated 09/1/2020, dated Electrocardiogram dated 8/26/20, COVID – 19 Negative report 8/31/20, Admission Agreement dated 9/1/20, Vitas Hospice care Medication list dated 10/1/20, Vitas Hospice Care visit list, Note from the family date- 11/10/20. LPA interviewed Staff 1 (S1) Staff 2 (S2) Resident 1 (R1) Vitas Nurse, residents daughter,
*Investigation into allegation of Facility staff left resident in soiled clothing for an extended period of time is unfounded.
Based on the interview with the R1,S1, S2, R1’s daughter R 1 was eating See’s Famous Old Time Candies (chocolate) and while he was eating the chocolate dropped on his cloths, not soiled but it was stain with chocolate. (Photo of the See’s Famous Old Time Candies provided)

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)

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Control Number 22-AS-20200921101517

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 of Facility staff do not assist resident with transfers out of bed is unfounded.
Interview of staff, R1’s Son and daughter and R 1 staff was assisting resident with transfer out of bed. Specially R 1 stated that S1 always help him.
R 1’s daughter stated that Her father R1 going on has 3rd month of hospice care at Iris Guest Home on Berkeley. They were given 2 to 3 weeks of life for her father. At this facility he has improved so much.. Not only in health but mentally. He is happy at the facility. R 1 also stated that he is getting good care at the facility.
*Investigation into allegation of facility staff are not providing resident with an adequate quality of food is unfounded.
Interview of the staff and reviews of Admission Agreement, Physician’s report R1 was on liquid diet. R 1 has no dentures, no teeth. He was on soft diet as he chokes when swallowing. R 1 and R1’s daughter said that facility providing food according to R1’s needs.

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 left resident in soiled clothing for an extended period of time facility staff do not assist resident with transfers out of bed, Facility staff are not providing resident with an adequate quality and quantity of food 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)

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