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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 03:24:47 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
03/29/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230329103817
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:
01:46 PM
MET WITH:Bonifacio Briones- CaregiverTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff yells at residents.
Facility staff threw resident's wheelchair.
Facility staff does not ensure that the facility is maintained at a comfortable temperature for the residents.
Facility staff does not properly store bed linens.
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 Dao 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: resident roster and LIC 500 (Personnel Report). In regards to the allegations Facility staff yells at residents; Facility staff threw resident's wheelchair; Facility staff does not ensure that the facility is maintained at a comfortable temperature for the residents; Facility staff does not properly store bed linens the investigation revealed the following:

Regarding the allegation Facility staff yells at residents, interviews conducted with Staff 1 (S1) and Administrator Dao deny allegations of yelling. S1 confirmed they do speak in a loud voice when speaking with residents due to residents being hard of hearing.
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 4
Control Number 22-AS-20230329103817
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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Interviews conducted with two of six residents in care confirmed that S1 does yell at residents. The remaining four residents were unavailable and/or unable to be interviewed due to communication barriers. LPA Mendivil reviewed S1’s personnel file and confirmed S1 has not received current training on resident’s personal rights. Training observed on file expired March 16, 2023, meaning it is older than 12 months time period. Although it does not appear S1’s elevated voice was done with malicious or mal intent, based on interviews conducted with S1 and multiple residents in care, the allegation is determined to be Substantiated.

It was alleged facility staff threw resident’s wheelchair due to staff becoming agitated and physically throwing Resident 1 (R1)’s wheelchair. Interviews conducted with S1 and Administrator Dao deny allegation. Interviews conducted with residents in care confirmed S1 can be rough at times when handling residents and/or their belongings. Although it does not appear S1’s rough handling was done with malicious or mal intent, based on interviews conducted with residents in care the allegation is determined to be Substantiated.

Regarding the allegation Facility staff does not ensure that the facility is maintained at a comfortable temperature for the residents. Based on observations made during LPA’s visit to the facility on 03/14/2023, LPA observed the facility to be maintained at a comfortable temperature meaning residents did not appear to be over heated, sweating and/or unreasonably cold. Temperature within the facility appeared to be maintained within regulatory requirements. Interviews with 3 out of 6 residents indicate that the temperature in the facility is comfortable. The remaining three residents were unable and/or refused to be interviewed. During a separate complaint investigation dated 1/20/2023 the allegation that Facility has no heat was substantiated. Therefore, the allegation facility failed to maintain temperature within regulatory requirements is deemed to be Substantiated. The facility was previously cited on 1/20/2023 for violation and has since corrected deficiency.

Regarding the allegation facility does not properly store bed linens, during previous visit dated 03/14/2023 LPA Mendivil observed bed linens being stored in a pile on facility outside patio. Patio was uncovered and accessible to outside elements. During follow up visit dated 4/7/2023 LPA observed linens had been freshly cleaned, sorted, and restored in a linen closet located within the facility. Based on LPA’s observations, the allegation that facility does not properly store bed linens is deemed 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 4
Control Number 22-AS-20230329103817
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
05/01/2023
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: 2 out of 6 residents stated that S1 yells. This poses a potential risk to persons safety in care.
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Administrator to conduct in staff training on personal rights and provide LPA with proof by POC due date.
Type B
05/01/2023
Section Cited
CCR
87468.1(a)(3)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...
This requirement was not met as evidence by: S1 has handled residents belongings in a rough manner.
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Administrator to conduct in staff training on handling residents belongings and provide LPA with proof by POC due date.
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This poses a potential risk safety 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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20230329103817
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
04/25/2023
Section Cited
CCR
87307(a)(3)(C)
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(3) Equipment and supplies necessary for personal care ... shall be readily available to each resident... (C) Clean linen... The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair…
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Administrator has since corrected issue. Linens are clean and properly stored inside closet in the facility.
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This requirement was not met as evidence by LPA observed linens in outside patio on 03/14/2023. This poses a potential health 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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4