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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 01/20/2023
Date Signed: 01/20/2023 03:57:13 PM

Substantiated


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
01/17/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230117165840
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:
01/20/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Leo Garias- CaregiverTIME COMPLETED:
02:59 PM
ALLEGATION(S):
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Facility has no heat
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced complaint visit. LPA was greeted and granted entry into the facility by Caregiver Leo Garias and explained the reason for the visit.

The department received a complaint on 01/17/2023. LPA Mendivil visited facility on 01/18/2023 . Regarding the allegation the facility has no heat,the investigation revealed the following:

LPA Mendivil observed the thermostat at 66 degrees fahrenheit on 01/18/2023 during the initial 10 day visit. During the complaint delivering visit the thermostat read at 66 degrees fahrenheit. Interviews with residents indicate they were told the facility heat is not working.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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 3
Control Number 22-AS-20230117165840
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: 01/20/2023
NARRATIVE
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Therefore based on the preponderance of evidence through interviews and observations the allegation that the facility has no heat is SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230117165840
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited
CCR
87303(b)(1)
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87303 Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times.
(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).
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Administrator to send photo proof daily until 01/26/2023 that the thermostat is at or above 68 degrees as Administrator stated the heater is working and is on.
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This requirement was not met as evidence by the facility thermostat read at 66 degrees.
This poses a potential heatlh and safety 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3