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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 05/25/2023
Date Signed: 05/25/2023 03:56:13 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
05/24/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230524125330
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:
05/25/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ben Briones - CaregiverTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff failed to keep facility free of vermin
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Caregiver Ben Briones and explained reason for the visit. Administrator/Licensee Brevet Dao arrived at 3:10pm.

The department received a complaint on 05/24/2023 and the initial 10 day visit was conducted on 05/25/2023. During the visit LPA toured the facility and interviewed residents and staff. Regarding the allegation Staff failed to keep facility free of vermin, the investigation revealed the following:

During the tour of the facility LPA Mendivil observed rodent droppings present in the living room, hallway cupboard and in resident's closets. Based on interviews with residents 1 out of 5 confirm they have seen rodents present in the facility. 4 out of 5 indicate they have not seen or heard any rodents, and the final resident was not available to interview due to not being oriented to space and time. CONT on 9099-C dated 05/25/2023
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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 3
Control Number 22-AS-20230524125330
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: 05/25/2023
NARRATIVE
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Based on interviews with staff indicated they have not seen a presence of rodents. Interviews with Administrator Brevet Dao indicate she has a contract with a pest control company and they have been out to the house to initiate protocols to safeguard from pest.

Therefore based on the preponderance of evidence through observation of rodent droppings and interviews the allegation that Staff failed to keep facility free of vermin is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

Civil Penalty assessed based on repeat violation.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

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

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230524125330
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: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operations: (a )The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee to immediately clean kitchen pantry and clean the facility and provide proof to LPA by POC date. Licensee to contact pest control company and provide LPA with date and time of next visit and forward proof to LPA by 06/01/2023.
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This requriement was not met as evidence by the facility had the present of rodent droppings in mulitple locations. This poses an immediate health and safety 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: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3