306005722-3-14-2023-22-AS-AORZ-CQUUJA-20230413153713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:10:04 PM

Unsubstantiated

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
02/23/2023 and conducted by Evaluator Andrea Mendivil

COMPLAINT CONTROL NUMBER: 22-AS-20230223151647

FACILITY NAME:	IRIS GUEST HOME		FACILITY NUMBER:	306005722
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	2702 N BERKELY ST		TELEPHONE:	(714) 602-7911
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 6	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Leo Garias- Caregiver		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff are not providing food in the quality and in the quantity necessary to meet the needs of the residents.

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. 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 02/23/2023 and the initial visit was conducted on 03/02/2023 by LPA Alvaro Ramirez Jr. During the course of the investigation, the Department interviewed staff, residents and witnesses. In addition the department obtained copies of facility menu. Regarding the allegation staff are not providing food in the quantity and quality necessary to meet the needs of the residents, the investigation revealed the following:

It was reported by witnesses that facility is providing residents with peanut butter and jelly sandwiches with spam for dinner and other meals include chicken and white rice. Based on observations by both LPAs Ramirez and Mendivil observed the refrigerator was stocked with eggs, bread, ham, and chicken. LPA Mendivil observed a sample menu on the refrigerator. CONT on 9099-c

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230223151647

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: 03/14/2023

NARRATIVE

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Based on interviews with Administrator Brevet Dao the menu is not always followed and it is modified. Administrator stated they try to accommodate all resident's dietary restrictions with are mostly low sodium and low carbohydrate meals. Interviews with staff indicate that groceries are purchased every 5 days

Based on interviews with 3 out 6 residents stated they thought the food was sufficient in quantity but lacked in quality. 2 remaining residents stated that the food was satisfactory for both quantity and quality. The final resident was unable to be interviewed as they are oriented to time and space. All interviewed residents mentioned cereal or oatmeal for breakfast, chicken and rice for lunch and soup and sandwiches for dinner.

Based on preponderance of evidence through observations and interviews the allegation that staff are not providing food in the quality and in the quantity necessary to meet the needs of the residents is UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

No deficiencies cited.
An exit interview was conducted and a copy of this report and confidential names list was provided

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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