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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 03/20/2023
Date Signed: 03/20/2023 02:45:46 PM

Document Has Been Signed on 03/20/2023 02:45 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
ORANGE & INLAND A/SC, 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:
03/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Brevet Dao, AdministratorTIME COMPLETED:
03:00 PM
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On this day, Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of conducting a Case Management inspection based on deficiencies observed during a complaint investigation visit for complaint #22-AS-20230317113524.

Upon arriving at the facility and before entering the premises, LPA could hear the facility's sound alarm from the smoke detectors inside the facility. Upon ringing the bell, knocking the door and being greeted by facility's caregiver staff, LPA was able to confirm that the alarms were being triggered by cooking fumes inside the house in spite of the extractor fan running and kitchen window being open. A deficiency is being issued per Title 22 Division 6 of the California Code of Regulations.

Later during the visit, LPA requested, obtained and reviewed facility records for the six individuals currently in care. Upon review of the residents' physician records, the following was observed:
- One resident admitted to the facility on January 14, 2023 had a physician report showing a date of examination of November 15, 2021, which is in excess of the required maximum of a year prior to admission.
- Two residents with a Dementia diagnosis show outdated physician reports that have not been reassessed over the past calendar year.
Two deficiencies to Title 22 regulations are cited to that extent.

An exit interview was conducted and a copy of this report, citations and appeal rights were provided to the facility representative via email.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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Document Has Been Signed on 03/20/2023 02:45 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 03/20/2023 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2023
Section Cited
CCR
87468.1(a)(2)

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The California Code of Regulations 87468.1(a)(2) on Personal Rights of Residents in All Facilities states that (a) Residents (...) shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee to ensure that all smoke detectors are in adequate working order. The extractor fan shall be verified to be of a sufficient capacity to avoir smoke alarms being triggered by staff cooking meals for the residents.
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This requirement is not met as evidenced by: Upon arriving at the facility, LPA observed smoke detectors being triggered across the entire facility by cooking fumes. This constitute a potential risk to the health, safety and personal rights of the individuals in care.
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Type B
04/17/2023
Section Cited
CCR87458(a)

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The California Code of Regulations Section 87458(a) on Medical Assessment states that "Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year."
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Licensee to obtain an updated medical assessment for the resident in question before the plan of corrections due date of April 17, 2023.
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This requirement is not met as evidenced by Record for one resident admitted to the facility on January 14, 2023 had a physician report showing a date of examination of November 15, 2021. This constitutes a potential risk to the health, safety and personal rights of the individuals 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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2023 02:45 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 03/20/2023 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited
CCR
87705(c)(5)

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The California Code of Regulations Section 87705(c)(5) on the Care of Persons with Dementia states that: "(5) Each resident with dementia shall have an annual medical assessment (...) done at least annually(...)."
This requirement is not met as evidenced by:
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Licensee to obtain updated medical assessments which shall include a reassessment of the resident’s dementia care needs before the plan of corrections due date.
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Based on a review of resident records kept at the facility, two residents with diagnosed dementia are showing medical assessments that have been conducted more than a year prior to the inspection's date. This constitutes a potential risk to the health, safety and personal rights of individuals 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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
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