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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 02/03/2023
Date Signed: 02/03/2023 03:20:08 PM

Document Has Been Signed on 02/03/2023 03:20 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:
02/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Leo Garias- caregiverTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPAs) Andrea Mendivil and Alvaro Ramirez conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 01/20/2023. LPAs were greeted and granted entry into the facility by Caregiver Leodigario Garias and explained the reason for the visit. Administrator Brevet Dao was unable to be present, but was available by phone.

Deficiency cited under Title 22 Regulation
  • 87303 (b) (1) ,licensee is using facility heater and facility temperature read at 70 degrees Fahrenheit


Licensee has complied with the POC.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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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