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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 03:27:31 PM

Unsubstantiated


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
04/03/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230403084619
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:
02:31 PM
MET WITH:Bonifacio Briones- CaregiverTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is not following resident's physician dietary orders.
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 the facility by Caregiver Bonifacio Briones. Administrator Brevet Dao was available by phone.

The department received a complaint on 04/03/2023 and the initial visit was conducted on 04/07/2023. During the visit LPA Mendivil obtained copies of physician reports , physician’s dietary recommendations, and sample menu. Regarding the allegation facility is not following resident’s physician dietary orders, the investigation revealed the following:

Per documentation Resident 1 (R1) was admitted to the facility on 02/02/2022. Based on review of LIC 602 Physicians Report dated 01/20/22 R1 does not require a special diet. LPA Mendivil obtained a copy of a letter, dated 11/03/2022, from R1’s physician with recommendation for dietary guidance.
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: 1 of 2
Control Number 22-AS-20230403084619
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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The letter serves as a recommendation to avoid processed foods, high carb vegetables, potatoes, and rice.

Based on interviews with Administrator Dao, Administrator acknowledged she has received the dietary recommendations from R1’s responsible party. Administrator Dao reported that the facility attempts to follow all recommendations and acknowledges will continue to follow recommendations as much as possible.

Therefore, based on the preponderance of evidence gathered, interviews conducted, records reviewed, and observations made the allegation that facility is not following resident’s physicians dietary orders is determined to be 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.

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: 04/25/2023
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 2