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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:40:25 AM

Document Has Been Signed on 10/17/2022 11:40 AM - 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:
10/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Leo Garais, caregiver
Brevet Gao, administrator		TIME COMPLETED:
12:00 PM
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On 10/17/2022, Licensing Program Analyst (LPA) conducted an unannounced visit to the facility for the purpose of following up on the plan of corrections resulting from the case management visit led on 10/14/2022. LPA was greeted and granted entry by caregiving staff after explaining the purpose of the visit.

LPA requested caregiver to demonstrate where the cleaning supplies are currently stored. Caregiver showed supplies have been moved to the garage.

LPA requested caregiver to show the medication storage. Centrally stored medication is adequately stored in a secure closet in the hallway leading to the bedrooms.

Two type A violations observed on 10/14/2022 are cleared at this time.

LPA conducted an exit interview, reviewed the report with the facility staff and left a copy of the report at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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