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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 06/20/2023
Date Signed: 06/20/2023 02:49:53 PM

Document Has Been Signed on 06/20/2023 02:49 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: 5DATE:
06/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Ben Briones- CaregiverTIME COMPLETED:
03:15 PM
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver amended report for Case Management dated 06/15/2023.

LPA Mendivil visited facility on 06/15/2023 and observed a resident had eloped. LPA Mendivil met with Ben Briones and discussed amended report to assess CIVIL PENALTY.

An exit interview was conducted with Ben Briones and a copy of this report, and amended LIC 809-D with LIC 421 IM and appeal rights were left at the facility.
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.

LIC809 (FAS) - (06/04)
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