Community Care Licensing

Document Has Been Signed on 03/14/2023 04:12 PM - It Cannot Be Edited

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
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	02:46 PM
MET WITH:	Leo Garias-		TIME COMPLETED:	04:25 PM

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

Link to Parent Document Below:

FACILITY NAME: IRIS GUEST HOME	FACILITY NUMBER: 306005722
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/15/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	(h) The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.	1 2 3 4 5 6 7	Licensee to remove all medications from unsecured area and place in secured location by POC due date and forward proof to LPA.
	8 9 10 11 12 13 14	This requirement was not met as evidence by facility had unsecured medication in the refridgerator which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 03/20/2023 Section Cited CCR87405(a)	1 2 3 4 5 6 7	All facilities shall have a qualified and currently certified administrator. . When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible... This requirement is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit a statement of understanding regarding designation of responsibility, LIC 308, and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on observation and interviews conducted, Licensee failed to ensure there was a designation of responsibility issued to LPA during absence of administrator. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Andrea Mendivil LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023

Link to Parent Document Below:

FACILITY NAME: IRIS GUEST HOME	FACILITY NUMBER: 306005722
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/16/2023 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to electronically send over files to LPA by POC due date. Licensee to keep files at facility or electronic records for review.
	8 9 10 11 12 13 14	Administrator had files at a separate location and was unable to produce them at the facility, which poses an immediate health and safety risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Alisa Ortiz LICENSING EVALUATOR NAME: Andrea Mendivil LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023