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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 04/20/2023
Date Signed: 05/19/2023 11:49:23 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
03/01/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230301162939
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:
04/20/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leo Garias- Caregiver TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility is malodorous.
Ombudsman poster is not posted in facility.
Facility did not administer medications to resident.
Resident was not given an admission agreement.
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Leo Garias and explained the reason for the visit. Administrator Brevet Dao was notified of LPA’s arrival and joined via telephone.

The Department received a complaint on 03/01/2023 and conducted the initial visit on 03/02/2023. LPA Alvaro Ramirez obtained copies of pertinent documents including but not limited to: medication records and admission agreements. In regards to the allegations Facility is malodorous; Ombudsman poster is not posted in facility; Residents are not provided adequate bedding; Facility did not administer medications to resident; and Resident was not given an admission agreement, the investigation revealed the following:

Regarding the allegation Facility is malodorous, LPA experienced a strong urine like odor coming from the bedroom of Resident 1 (R1) and Resident 2 (R2) during multiple visits to the facility.
** This is an amended report **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
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 6
Control Number 22-AS-20230301162939
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: 04/20/2023
NARRATIVE
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LPA confirmed R1 and R2 require incontinence care assistance from facility staff. LPA interviewed residents but was unable to determine frequency of incontinence services.

Regarding the allegation the Ombudsman poster is not posted in the facility, LPA Alvaro Ramirez confirmed via photograph taken that Ombudsman poster was not properly posted in a visible location. While the facility was observed to have a poster present in the building, poster was observed laying on an end table in facility living room.

Regarding the allegation Facility did not administer medications to resident, LPA confirmed Resident 3 (R3)’s medication was being rationed by facility staff due to pharmacy failing to provide refill for prescription on time. LPA spoke with Administrator Brevet Dao who stated she did reach out to the pharmacy once notified the pharmacy failed to refill medication on time. R3’s physician was not notified of the missed medication dosages.

It was alleged resident was not given an admission agreement due to R3 not receiving an admission agreement. LPA interviewed R3 who confirmed they did not receive a copy of admission agreement upon moving in. R3 reported they were provided an Admission Agreement on 3/04/23 by Administrator Dao for signature. R3 moved into the facility on 12/18/2021.

Therefore, based on the preponderance of evidence gathered, the allegations that Facility is malodorous; Ombudsman poster is not posted in facility; Residents are not provided adequate bedding; Facility did not administer medications to resident; and Resident was not given an admission agreement are determined to be Substantiated.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted with Administrator and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit.

* Due to technical difficulties LPA was unable to print document, document emailed to Administrator

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 22-AS-20230301162939
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: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2023
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administrator create a schedule for cleaning and incontinence care and provide proof to LPA by POC due date.
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This requirement is not met as evidence by the facility bedroom of R1 and R2 had a strong urine odor. This poses a potential health and safety risk to persons in care,
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Type B
04/26/2023
Section Cited
HSC
1569.269(a)(12)
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To contact the ... ombudsman ... The licensee shall post the telephone numbers and addresses for the local offices ... and ombudsman program, in accordance with Section 9718 of the Welfare and Institutions Code, conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents.
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Administrator has since corrected the deficency. Ombudsman poster is displayed in the facility entryway.
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This requirement was not met as evidence by LPA Ramirez took photographic evidence of ombudsman poster on a table in the living room. This poses a potential health and safety risk to persons 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20230301162939
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: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2023
Section Cited
HSC
87464(f)(4)
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87464 (f)Basic services shall at a minimum include:(4)Personal... assistance with taking prescribed medications...This requirement was not met as evidenced by based on interviews facility was rationing R3's medication.
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Administrator to ensure all medications are refiled as necessary.
Type B
04/21/2023
Section Cited
CCR
87507(C)
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Admission Agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, and the licensee no later than seven days following admission. This requirement was not met as evidence by R3 did not sign agreement until 3/4/2023. R3 entered facility on 12/18/2021
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Administrator has since retained a signed copy on file and provided R3 with a copy of signed admission agreement,
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This poses a potential health and safety risk to persons 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
03/01/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230301162939

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:
04/20/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leo Garias- Caregiver TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents are not provided adequate bedding.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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10
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12
13
On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Leo Garias and explained the reason for the visit. Administrator Brevet Dao was available via telephone.

The Department received a complaint on 03/01/2023 and conducted the initial visit on 03/02/2023. LPA Alvaro Ramirez obtained copies of pertinent documents including but not limited to: medication records and admission agreements. In regards to the allegation Residents are not provided adequate bedding

During LPA’s visits to the facility LPA reviewed 6 of 6 resident’s bed linens. LPA confirmed facility does have required bedding including but not limited to: clean linen, blankets, bed spreads, top sheet, bottom sheet, pillow case, and mattress pads. LPA confirmed facility has additional blankets on hand for residents as needed. Per interviews with staff and resident there are times when several items such as bed sheets or blankets were a resident does not wish to have them on the bed. ** This is an amended report **
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20230301162939
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: 04/20/2023
NARRATIVE
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Therefore based on preponderance of evidence through records reviewed, observations made and interviews conducted the allegation Residents are not provided adequate bedding is determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. 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: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6