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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 03/03/2023
Date Signed: 03/03/2023 11:44:06 AM

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
01/27/2023 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230127111023
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: 5DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Staff Leo GarraisTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility did not accompany resident to medical appointment
Facility has insects
INVESTIGATION FINDINGS:
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Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Staff Leo Garrais. Administer Brevet Dao spoke with LPA about the findings via telephone and stated she could not come to the facility. The complaint was investigated and consisted of interviews with the facility staff, Administrator and witnesses. The following was determined:

Resident #1 (R1) was admitted into the facility on 12/27/22. R1 had Renal Failure and needed to attend Dialysis three times a week. R1 was confused and disoriented. and needed assistance with all his ADL's. He used a wheelchair to ambulate and needed assistance to get into the wheelchair. He could not leave the facility unassisted.

Upon admission, no admission agreement was signed and according to staff and witnesses the POA was informed that the facility staff would take care of the transportation to medical appointments since R1 needed assistance. On 1/4/23, R1 was sent to Dialysis in an Uber. When he arrived, there was no staff to take him from the car into his appointment. Dialysis staff had to bring R1 inside and it was raining.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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 5
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
01/27/2023 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230127111023

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: 5DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Staff Leo GarraisTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not seek medical treatment for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Staff Leo Garrais. Administer Brevet Dao spoke with LPA via telephone about the findings and stated she could not come to the facility. The complaint was investigated and consisted of interviews with the facility staff, Administrator and witnesses. The following was determined:

Resident #1 (R1) was admitted into the facility on 12/27/22. On 1/4/23, while at Dialysis, R1 became unconscious and 911 was contacted. R1 was transported to the hospital. R1 was admitted for cardiac arrest. During R1’s hospital visit, it was also discovered that R1 had a right hip fracture and surgery was performed.

It is unknown when R1 broke his hip. He had a fall at home on 12/6/22, prior to coming to the facility. He did go to the hospital for treatment. Interviews did not disclose another fall during the week R1 lived at the facility or at dialysis on 1/4/23.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20230127111023
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: 03/03/2023
NARRATIVE
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Based upon a review of records and the interviews conducted the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that R1 broke his hip at the facility.

An exit interview was conducted and a copy of this report and appeal rights were provided to Leo Garrais.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230127111023
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: 03/03/2023
NARRATIVE
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According to interviews a staff member and a medical transport with wheelchair access should have been used to assist R1.

On 1/27/23 during the initial 10 day visit, LPA noted rodent droppings and baby cockroaches in the food pantry. Staff immediately removed all food and cleaned the pantry. Administrator Dao was also notified.

Based upon a review of records and the interviews conducted the preponderance of evidence standard has been met and the allegations are substantiated.

See LIC9099D for cited deficiencies per Title 22 regulation.

An exit interview was conducted and a copy of this report and appeal rights were provided to Staff Leo Garrais.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20230127111023
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: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2023
Section Cited
CCR
87465(a)(1)
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87465(a)(1)Incidental Medical and Dental Care-The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement was not met as evidenced by:
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Licensee agrees to meet with residents and/or their responsible party upon admission to sign an admission agreement and decide what type of transportation and supervision is needed and/or expected by the resident and family to meet the resident’s needs. Proof of understanding of this subsection will be provided by Licensee.
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On 1/4/23, R1 was sent to Dialysis in an Uber. No staff accompanied him and the Uber did not have wheelchair access. This poses an immediate health and safety risk as well as a personal rights risk to residents in care.
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Type A
03/04/2023
Section Cited
CCR
87307(d)(2)
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Personal Accommodations and Services-The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
This requirement was not met as evidenced by:
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On 1/27/2023, LPA observed rodent droppings and small cockroaches in the food pantry of the facility. This pose an immediate health and safety risk to residents in care.
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Staff #1 immediately removed food, cans and other containers from the pantry and cleaned the shelves. LPA notified Administrator Brevet Dao. Licensee agrees to hire an exterminator to rid the facility of cockroaches as well as rodents. Proof that an exterminator was contacted and a contract put in place will be provided by 3/3/23.

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: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5