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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:22:51 PM

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
03/06/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230306140958
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:
04/25/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Bonifacio Briones- Caregiver TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility unlawfully raised resident's rent
Facility unlawfully evicted resident
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 Bonifacio Briones and explained the reason for the visit. Administrator Brevet was available by phone.

The Department received a complaint on 03/06/2023 and conducted the initial visit on 03/14/2023. LPA Andrea Mendivil obtained copies of pertinent documents including but not limited to: admission agreements and resident files, and rent increase letter. In regards to the allegations Facility unlawfully raised resident's rent and Facility unlawfully evicted resident the investigation revealed the following:

Regarding the allegation facility unlawfully raised resident’s rent, LPA verified that 3 of 6 residents in care received a written notice of rate increase from Administrator Dao via text message. Text messages received included a photograph of a written 60 day notice dated February 25, 2023 notifying individuals of rate increase.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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
Control Number 22-AS-20230306140958
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: 04/25/2023
NARRATIVE
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Per written notice observed, written notice failed to address general description of the additional costs. LPA spoke with Administrator Dao who reported the rate increase was due to a change in basic service costs. Administrator Dao did not submit written change in Plan of Operation and/or Admission Agreement to the Department prior to providing residents with notice.

Regarding the allegation facility unlawfully evicted resident, it was reported Resident 1 (R1)’s responsible party received a text message from Administrator Dao asking them to relocate R1 from the facility due to the facility needing to close. Text message received did not include required written standards as outlined in Eviction Procedures per Title 22 Section 87224.

Therefore, based on the preponderance of evidence gathered, the allegations that Facility unlawfully raised resident's rent and Facility unlawfully evicted resident 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.

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

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
03/06/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230306140958

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:
04/25/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Bonifacio Briones- CaregiverTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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2
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5
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9
Facility Administrator is retaliating against Resident
INVESTIGATION FINDINGS:
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5
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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 Bonifacio Briones and explained the reason for the visit. Administrator Brevet Dao was reached via telephone.

The Department received a complaint on 03/06/2023 and conducted the initial visit on 03/14/2023. LPA Andrea Mendivil obtained copies of pertinent documents including but not limited to: admission agreements, resident records and rent increase letter. In regards to the allegation Facility Administrator is retaliating against Resident the investigation revealed the following:

It was alleged facility Administrator is retaliating against resident due to Administrator Dao’s multiple contact attempts with residents/ their responsible parties as well as rate increases. It was reported Administrator Dao provided a resident with a rate increase due to multiple complaints filed against facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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-20230306140958
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: 04/25/2023
NARRATIVE
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During the investigation LPA confirmed rate increases were not specific to one resident but rather provided to multiple residents due to increase utilities, commodities and workforce costs. Although it was confirmed Dao had made multiple attempts to contact resident/ their responsible party documentation provided could not confirm contacts were made with a malicious intent.

Therefore, based on the preponderance of evidence gathered, the allegations that Facility Administrator is retaliating against Resident 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.
An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230306140958
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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2023
Section Cited
CCR
87507(g)(4)
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(g) Admission agreements shall specify the following:(4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change...
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Administrator to update admission agreements and Plan of Operations with update basic rate and what is included with basic rate.
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This requirement was not met as evidence by Administrator did not update Plan of Operations or Admission Agreement with new rate. This poses a potential risk to personal rights for persons in care.
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Type B
04/26/2023
Section Cited
CCR
87224(a)
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(a) Eviction Procedures: (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by:
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Administrator to review eviction procedures and update in Plan of Operations/ Admission Agreement by POC due date and forward proof to LPA.
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Administrator sent R1's responsible party a text message asking R1 to relocate.
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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: 04/25/2023
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 5