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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:18:14 PM

Document Has Been Signed on 04/27/2023 12:18 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
CCLD Regional Office, 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: 0DATE:
04/27/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brevet Dao - Licensee/Administrator TIME COMPLETED:
12:20 PM
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On today's date, Licensing Program Manager (LPM) Alisa Ortiz and Licensing Program Analyst (LPA) Andrea Mendivil met with Licensee Brevet Dao on this day for the purpose of discussing ongoing facility issues.


The following was discussed:
· Concerns regarding recent Substantiated complaints at Licensee’s facility Iris Guest Home.
· Licensee's responsibilities of facility oversight
· Licensee's requirement to assess residents prior to admission and ensure all preadmission paperwork is completed
· Licensee's responsibility to ensure all staff is trained and training is up to date
· Licensee’s responsibility to ensure physical plant is maintained and free of insects and vermin
· Licensee’s responsibility to ensure medications are received, provided and maintained as prescribed

The Licensee Stated as following during today's meeting:
· Licensee will designate a staff as Facility Designated Administrator Back up
- Licensee will retrain staff in personal rights and medications
- Licensee will provide more oversight at the facility including spending more time at the home
- Licensee will review and maintain all facility paperwork
- Licensee will ensure facility is following all required policy and procedures regarding rate increases and evictions

CONT on LIC 809- C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/27/2023
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During the meeting the Department’s Technical Support Program (TSP) was discussed with Licensee. Licensee expressed interest in Technical Support Program (TSP) and has agreed to participate.

Licensee was made aware of the seriousness of recent substantiated allegations and deficiencies issued. Licensee was placed on a compliance plan for a period of one years time effective 04/272023.

An exit interview was conducted with Licensee Brevet Dao and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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