<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 10/17/2023
Date Signed: 10/17/2023 02:55:35 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
07/21/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230721153400
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:
10/17/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Brevet Dao- Licensee/Administrator TIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not meeting resident's needs.
Facility is malodorous.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Jean Vera Cruz, caregiver and explained the reason for the visit. Licensee/Administrator Brevet Dao arrived at 10:40 am.

The department received a complaint on 07/21/2023 and LPA Cho conducted the initial 10 day visit on 07/28/2023. During the course of the investigation LPA Cho interviewed staff and residents. LPA Mendivil obtained copies of apprasials/needs and services plans. Regarding the allegations that Staff is not meeting resident's needs and facility is malodorous, the investigation revealed the following:

LPA Mendivil reviewed 4 out of 4 residents files. Per review 4 out of 4 Appraisal/Needs and Services Plan did not provide actionable objectives/plans. Review of Resident 1 (R1) Appraisal/Needs and Services Plan dated 12/01/2022 indicating R1’s diagnosed with Parkinson’s Disease, atrial fibrillation, hypertension, bipolar, mild cognitive impairment, depression, and unsteady gait. CONT on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
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-20230721153400
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: 10/17/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For the category of Physical/Health it is noted that “because of Parkinson’s affecting him, his physical mobility has been affected” it was noted that Physical Therapist (PT) and Occupational Therapist (OT) would be responsible for this need. Based on interviews with Administrator as of the date 12/02/2022 no PT/OT has seen R1.

Review of Resident 2 (R2) Appraisal/Needs and Services Plan dated 01/14/2023 indicating R2 is diagnosed with depression, psychosis, and dementia. In the category of Emotional Needs, it is noted “he is able to adjust emotionally and no issues”. For the objective/plan for the emotional need the objective is “to continue to monitor”, per review there is no actionable item to monitor. Based on LPA’s observations of R2, R2 remains in his room and does not socialize with house mates.

Review of Resident 3 (R3) Appraisal/Need and Services Plan dated 04/14/2023 indicating R3 is diagnosed with dementia, hypertension, and glaucoma. It is also noted that R3 needs assistance with all activities of daily living. In the category for Functioning Skills, it is noted "due to generalized weakness overall body function is affected", for the objective/plan "encourage to mobilize extremities, perform exercises on both hands and feet" the care team is responsible for this action. Based on interviews with witnesses, PT has been utilized but care giving staff has not.

Review of Resident 4 (R4) Appraisal/Need and Services Plan dated 06/02/2023 indicating R4 is diagnosed with wernickie's encephalopathy and dementia. Per review of all five category's did not list any services for a diagnosis of dementia.

Regarding the facility being malodorous LPA Mendivil experienced a strong smell of body odor and urine when entering the room of R1 and R3 on multiple occasions, no explanation provided from staff.

Therefore, based on evidence through records reviewed and interviews the allegations that Staff is not meeting resident's needs and facility is malodorous are 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 is assessed due to repeat violation within 12 months.

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: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230721153400
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: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2023
Section Cited
CCR
87464(a)
1
2
3
4
5
6
7
(a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care...
1
2
3
4
5
6
7
Licensee to update resident needs and services. Licensee stated will keep records of actions taken and outcomes daily.
8
9
10
11
12
13
14
This requirement was not met as evidence by in 4 out of 4 residents needs and services did not provide actionable items to assist residents in any given category. This poses a potential risk to persons in care.
8
9
10
11
12
13
14
Type B
10/23/2023
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
1
2
3
4
5
6
7
Licensee has a cleaning schedule and as of 10/17/2023, the facility no longer is malodorous.
8
9
10
11
12
13
14
This requirement was not met as evidence by LPA Mendivil experienced a strong body odor and urine smell from R1 & R3's room. This poses a potential health and safety risks to persons in care.
8
9
10
11
12
13
14
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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3