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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:43:03 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
06/12/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230612075559
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: 3DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brevet Dao- Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility failed to provide afternoon snacks to residents
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 Jean Vera Cruz and explained the reason for the visit. Administrator Brevet Dao arrived shortly after.

The Department received a complaint on 06/11/2023 and the initial 10 day visit was conducted by LPA Cho on 06/20/2023. During the visit LPA Cho interviewed residents and staff. LPA Mendivil conducted a follow up visit on 08/15/2023 during another complaint visit for 22-AS-20230808134542. LPA Mendivil observed kitchen pantry and refrigerator. Regarding the allegation facility failed to provide afternoon snacks to residents, the investigation revealed the following:

Based on interviews with staff 2 out of 2 staff stated they have snacks available for residents. Based on interviews with 2 out of 4 residents indicate there is food and snacks available in the home. CONT on LIC 9099-C dated 12/14/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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 2
Control Number 22-AS-20230612075559
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: 12/14/2023
NARRATIVE
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The remaining 2 residents could not confirm or deny if there are snacks available in the home. LPA Mendivil observed snack and fruit in the refrigerator. Based on Department regulation, 87555 General Food Service Requirements, regarding snacks states " (b)The following food service requirements shall apply: (3) Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician."

Therefore based on the preponderance of evidence through interviews and observation the allegation Facility failed to provide afternoon snacks to residents 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 was provided to facility Administrator.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
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