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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 05/19/2023
Date Signed: 05/19/2023 11:48:59 AM

Document Has Been Signed on 05/19/2023 11:48 AM - 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: 5DATE:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Ben Briones - Caregiver TIME COMPLETED:
12:15 PM
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver amended findings for complaint 22-AS-20230301162939

LPA delivered amended findings to facility on 04/20/2023. LPA Mendivil met with Ben Briones and discussed amended report.

An exit interview was conducted with , and a copy of this report, and amended report of findings delivered on 04/20/2023 were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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