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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:09:21 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
04/14/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230414130816
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:
06/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ben Briones- Caregiver TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not seek medical care for resident in care
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 Ben Briones and explained the reason for the visit.

The deparmtnet received a complaint on 04/14/2023 and the department conducted the initial 10 day visit on 04/20/2023. During the course of the investigation LPA Mendivil interviewed staff and resident and obtained copies of pertinent documents such as physician reports. Regarding the allegation staff did not seek medical care for resident in care.

Based on witnesses accounts Resident 1 (R1) fell sometime in the PM hours and R1 was on the floor. It was reported that staff was called into R1's room and picked up R1 and placed R1 back into bed. Per review of R1's physicians report dated 01/22/2022 does not indicate R1 is a fall risk.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
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 6
Control Number 22-AS-20230414130816
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: 06/20/2023
NARRATIVE
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Based on witness' statements a physical therapist conducted an assessment on 03/30/2023 and R1 did not complain of pain and did not exhibit pain behaviors. Based on witness statements another assessment was conducted on 04/10/2023 a complete head to toe assessment and did not observe any indications of pain or injury. R1 was unable to be interviewed as R1 would not answer LPA Mendivil's questions.

The facility staff was unable to confirm if R1 fell on 4/5/2023. Staff reported that if a resident was to fall and complain of pain they would call 911. Staff reported that in this case R1 did not complain of pain in the following days. Due to conflicting information from facility and witnesses it cannot be ascertained whether or not the facility did not seek medical care.

Therefore based on the preponderance of evidence through record review and interviews the allegation that Staff did not seek medical care for resident in care 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: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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
04/14/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230414130816

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:
06/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ben Briones- CaregiverTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff did not follow proper reporting requirements
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Caregiver Ben Briones and explained the reason for the visit.

The department received a complaint on 04/14/2023 and the initial 10 day visit was conducted on 04/20/2023. During the course of the initial visit, LPA Mendivil obtained copies of pertinent documents such as physican reports. Regarding the allegation that Staff did not follow proper reporting requirements, the investigation revealed the following:

It was reported by witnesses that a resident had an unwitnessed fall and no report was made to the department. Based on interviews with Administrator Brevet Dao, Brevet is disputing a fall occurred with resident 1 (R1) and therfore no report was needed. Based on further interviews with Administrator Brevet Dao there was an incident with Resident 2 (R2) in which the resident was only at the facility for a short time
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20230414130816
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: 06/20/2023
NARRATIVE
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It was reported that R2 had to go to the hospital and did not return to the facility upon discharge. A report was never received for the incident with R2. Based on interviews with Administrator Brevet Dao Unusual/Serious Injury Report (LIC 624) form was not sent for the incident of R2.

Though there is a dispute of a fall occurring with R1, the facility has not followed reporting requirements in a separate incident with R2. Therefore based on preponderance of evidence through record review and interviews the allegation Staff did not follow proper reporting requirements 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.

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: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20230414130816
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: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2023
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following…A written report…Any incident which threatens the welfare, safety or CONTINUED..
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Licensee/Administrator to review reporting requirement regulations and provide proof of understandin by POC due date
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health of any resident…This requirement is not met as evidence by: Licensee failed to submit a written report to CCLD for an incident with R2. This poses a potential 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: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6