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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 06/15/2023
Date Signed: 06/15/2023 04:29:38 PM

Document Has Been Signed on 06/15/2023 04:29 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: 4DATE:
06/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Ben Briones - Caregiver TIME COMPLETED:
04:15 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in conjunction with Complaint Control Number 22-AS-20230613154512. LPA was greeted and granted entry into the facility by caregiver Ben Briones and explained the reason for the visit.

During the course of the complaint visit LPA Mendivil reviewed Resident's 1 (R1) Physician Report (LIC 602) dated 01/02/2023, which indicates R1 is not allow to leave the facility unassisted. LPA Mendivil was not able to speak to R1 as R1 left the facility unassisted at 8am. Staff indicated R1 signed out and left and did not report when they would return

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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Document Has Been Signed on 06/20/2023 02:51 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/20/2023 01:06 PM


Created By: Andrea Mendivil On 06/15/2023 at 03:12 PM
Link to Parent Document Below:
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2023
Section Cited
CCR
87464(f)(1)

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87464 Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by, LPA observed a resident had left the faciltiy
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Licensee to review all residents' LIC 602 and provide in service regarding residents ability to leave facility
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unassisted, when 602 stated R1 cannot leave the facility unassisted. This causes 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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
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