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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:54:33 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
07/07/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230707154552
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:
03/27/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gemma Wanawan - Caregiver TIME COMPLETED:
01:29 PM
ALLEGATION(S):
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Staff did not follow doctor's dietary orders for resident in care
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced to deliver findings. LPA was greeted and granted entry into facility by Gemma Wanawan, Caregiver and explained the reason for the visit. Administrator Brevet Dao was available by phone.

The Department received a complaint on 07/07/2023 and LPA Mendivil conducted the initial 10 day visit on 07/11/2023. During the visit LPA obtained copies of sample menus and interviewed residents and staff. Regarding the allegation Staff did not follow doctor's dietary orders for resident in care, the investigation revealed the following:

Based on interviews with 1 out of 2 staff indicated they were unaware that any of the residents had a prescribed modified diet. Interviews with 2 out of 4 residents indicated they do not have a specific diet, the 2 other residents would not answer LPA Mendivil's questions.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
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-20230707154552
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: 03/27/2024
NARRATIVE
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 Per review of resident’s files Resident 1 (R1) does have a prescribed diet which was provided to the facility in June/July of 2023. Based on interviews with 2 witnesses the meals provided to R1 did not contain the food groups in the prescribed diet.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegations that staff did not follow doctor’s dietary orders for resident in care 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: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230707154552
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: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2024
Section Cited
CCR
87555(b)(7)
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(b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidence by 1 out of 2 staff was not aware of Resident 1's prescribed diet.
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Licensee agreed to provide in service to staff on renal diets and other possible diets that residents may have. Licensee agreed to keep a log of groceries purchased to prepare meals and provide proof to LPA by POC due date.
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This poses a potential health risks 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: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3