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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 12/05/2023
Date Signed: 12/05/2023 12:03:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/17/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230317113524
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: 2DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brevet Dao, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not seek timely medical assistance

Facility lacked care and supervision resulting in a resident's malnourishment
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the allegation listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Brevet Dao was notified of the visit and arrived later to assist. The allegations investigated were presented to the administrator.

An initial complaint investigation visit was conducted by LPA Saborit-Guasch on March 20, 2023. The complaint was investigated by the Department and consisted of a review of staff and resident’s records, a physical plant inspection and interviews of staff, witnesses and residents. Emergency Medical Transport records were obtained in addition to hospital records from Orange County Global and Kaiser Hospital.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
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-20230317113524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722
VISIT DATE: 12/05/2023
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
CONTINUED FROM FORM LIC9099

Resident R1 was admitted to the facility on August 29, 2022. Physician record dated August 28, 2022, documents resident’s weight to be 208 pounds. R1’s medical history upon admission is noted to be “atrial fibrillation, history of recurrent Deep Vein Thrombosis and Pulmonary Embolism, hypothyroidism, a history of diastolic congestive heart failure and adrenal insufficiency”. R1’s Preplacement Appraisal Information also includes “Celiac disease [Defined by the Mayo Clinic as “an illness caused by an immune reaction to eating gluten. Gluten is a protein found in foods containing wheat, barley or rye. If you have celiac disease, eating gluten triggers an immune response to the gluten protein in your small intestine. Over time, this reaction damages your small intestine's lining and prevents it from absorbing nutrients, a condition called malabsorption”], Diarrhea, Fall risk, hypertension, orthostatic hypotension (…) and long term warfarin usage”. Hospital notes from Kaiser dated November 19, 2022, state a weight of 186 pounds.

On November 18, 2022, R1 was transferred to Orange Global Hospital for chest pain, constant, sub-sternal, pressure-like, non-radiating with pain at 8/10 after a facility caregiver measured R1’s blood pressure at 188/109 with an elevated heart rate. Administrator and responsible party were notified. During the initial assessment at the hospital, R1’s Body Mass Index was calculated to be 25.9, placing the resident in a normal range. R1 was then transferred to Kaiser Hospital on November 19, 2022.

An interview with R1’s Kaiser Primary Care Physician was conducted to review the medical diagnoses based on nutritional assessment conducted by a Kaiser RN stated that R1 “qualifies for severe malnutrition in the context of chronic illness, as of 11/20/2022. Weight loss: -12 kg weight loss over 3 months = 12.5%. Loss of subcutaneous fat: mild-moderate loss at upper arm region (triceps). Muscle loss: moderate loss at clavicle bone region, moderate loss at acromion bone region (shoulders), moderate loss at scapular bone region, mild-moderate loss in quadriceps and/or calf region (legs)”. According to the physician if R1’s body mass index was less than 18.5 that would qualify him as being underweight, the fact he did have loss of subcutaneous fat and loss of muscle mass could have been contributed by his Celiac Disease. R1’s Body Mass Index was 25.9, which health experts would say was a healthy number for someone of his height.

CONTINUED ON FORM LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20230317113524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722
VISIT DATE: 12/05/2023
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
CONTINUED FROM FORM LIC9099-C

Regarding the allegation that Facility did not seek timely medical assistance, the following has been concluded: Based on interviews conducted with facility staff, witnesses as well as a review of records resulting from a call to paramedics made on November 17, 2022, and subsequent hospital admissions at Orange County Global Hospital and Kaiser Hospital, facility staff measured R1’s blood pressure to be elevated. Following this, both the facility administrator and R1’s authorized representative were notified. R1’s authorized representative appears to have placed the call to the paramedics upon her arrival at the facility, however no lapse of time in contacting the paramedics was evidenced due to potential facility staff neglect.
As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Regarding the allegation that Facility lacked care and supervision resulting in a resident's malnourishment, the following has been concluded: Based on interviews conducted with facility staff, witnesses as well as a review of records resulting from a call to paramedics made on November 17, 2022 and subsequent hospital admissions at Orange County Global Hospital and Kaiser Hospital, both a sufficient Body Mass Index of 25.9 and a potential history of weight loss evaluated at approximately “12.5%, [with] loss of subcutaneous fat: mild-moderate loss at upper arm region, muscle loss: moderate loss at clavicle bone region, moderate loss at acromion bone region, moderate loss at scapular bone region, mild-moderate loss in quadriceps and calf region”. An interview conducted by telephone with R1’s primary care provider at Kaiser Hospital evidenced that “[R1]’s body mass index is fine for his body mass” and further hypothesized that the documented celiac disease could have been a contributing factor in the loss of subcutaneous fat and loss of muscle mass described by the hospital staff.

Therefore the evidence is not sufficient to establish both the actual state of malnutrition and whether it can be attributed in part or in full to the facility’s lack of care and supervision. The allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/17/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230317113524

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: 2DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brevet Dao, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have sufficient staffing to meet residents' needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the allegation listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Brevet Dao was notified of the visit and arrived later to assist. The allegation investigated was presented to the administrator.

An initial complaint investigation visit was conducted by LPA Saborit-Guasch on March 20, 2023. The complaint was investigated by the Department and consisted of a review of staff and resident’s records, a physical plant inspection and interviews of staff, witness and residents. Emergency Medical Transport records were obtained in addition to hospital records from Orange County Global and Kaiser Hospital.

CONTINUED ON FORM LIC9099
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20230317113524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722
VISIT DATE: 12/05/2023
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
CONTINUED FROM FORM LIC9099

During the initial investigation, LPA was provided with a copy of Facility Roster form LIC500 dated January 18, 2020. The licensee did not provide any other updated staff’s schedule. During the investigation, four individual staff members were identified as providing care and supervision at the facility, with shifts covering both day time and night time hours. However, on multiple instances of Department’s inspection to the facility, response delays were noted due to the fact that staff members were actually covering both the present facility and the adjacent facility (Jade Guest House, license number 306006062). One single staff member cannot be deemed sufficient to take care of two separate facilities without a centralized call system, both with a capacity of six residents including some bedbound residents. Without actual schedules, it could not be established whether this was a regular occurrence, however two separate facility visits resulted in the same deficiency being observed and a civil penalty for a repeat violation was issued to the licensee.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met.

A Type A citation is issued on the attached form LIC9099-D.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20230317113524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2023
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
(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 is not met as evidenced by: Based on observation conducted at the facility, on at least (...)
1
2
3
4
5
6
7
Licensee offers to provide documentation of the elapsed week from the present visit until the plan of correction due date to demonstrate staffing and adequate coverage.
8
9
10
11
12
13
14
 two separate occasions staff members were observed to be absent from the premises. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
8
9
10
11
12
13
14
This 9099-D was amended to modify the plan of corrections due date per Department policy.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6