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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:17:43 PM

Document Has Been Signed on 10/14/2022 02:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
306005722
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2702 N BERKELY STTELEPHONE:
(714) 602-7911
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 6DATE:
10/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Leodigario Garais, caregiver
Brevet Dao, Administrator (via phone)		TIME COMPLETED:
02:45 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced case management visit after observing multiple deficiencies at the twin facility operated by licensee. LPA was greeted and granted entry by caregiving staff after identifying himself and explaining the purpose of the visit. Administrator Brevet Dao was notified by phone, but was not available to assist with the visit in person. Infection Control measures were reviewed over the phone. Administrator agreed to review the final report over the phone as well and authorized her staff to sign on her behalf.

After being greeted, LPA observed caregiver spray deodorizer around the hallway and bathroom after emptying a urine container in the toilet. Floor was afterwards observed to be wet and slippery throughout, which poses a safety hazard due to the risk of slipping.

The medication central storage in a hallway closet is also observed to be unlocked at the time of the visit.

Cleaning solutions and other potentially toxic substances are also observed to be stored in the laundry closet which is left unlocked after the padlock hinges broke off.

Based on the observations made during today’s visit, three deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed over the phone with facility administrator and signed by authorized facility representative. A copy of this report along with appeal rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2022 02:17 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 10/14/2022 at 01:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2022
Section Cited
CCR
87465(h)(2)

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The California Code of Regulations Section 87465(h)(2) relative to Incidental Medical and Dental Care indicates that: "Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication."
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Licensee will ensure that centrally stored medication remain locked and secure at all times.
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This requirement is not met as evidenced by: LPA observed that staff present had left the door to the medication closet unlocked while conducting the inspection visit. Caregiver states that they only lock the medication "when they sleep".
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Type A
10/17/2022
Section Cited
CCR87705(f)

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The California Code of Regulations Section 87705(f) relative to the Care of Persons with Dementia indicates that: "The following shall be stored inaccessible to residents with dementia: (...) nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances"
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Licensee will ensure the safe and secure storage of all the identified objects and substances by the Plan of Correction due date.
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This requirement is not met as evidenced by: LPA observed sharp instruments, cleanings solutions, insecticide and/or rodenticide and nutritional supplements left unsecured throughout the physical plant.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/14/2022 02:17 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 10/14/2022 at 01:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited
CCR
87303(a)

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California Code of Regulations Section 87303(a) Maintenance and Operation states that "The facility shall be clean, safe, sanitary and in good repair at all times. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition".
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Licensee will ensure the facility is kept clean, safe and sanitary before the plan of corrections due date.
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This requirement is not met as evidenced by: Licensing staff observed deodorizer spray making the floor wet and slippery during the inspection visit. Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
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