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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 04/15/2024
Date Signed: 04/29/2024 02:39:31 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
06/13/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230613154512
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: DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Brevet Dao - Adminstrator/Licensee TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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facility tried to prevent resident from being taken to the hospital by family
facility staff decided resident should be on hospice
facility did not keep accurate resident records
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 XX and explained the reason for the visit.

The Department received a complaint on 06/12/2023 and LPA Mendivil conducted the initial 10 day visit on 06/15/2023. LPA Mendivil interviewed staff and residents and obtained copies of pertinent documents such as physician report, admission agreement and hospice documentation. Regarding the allegation facility tried to prevent resident from being taken to the hospital by family, facility staff decided resident should be on hospice and facility did not keep accurate resident records, the investigation revealed the following:

Resident 1 (R1) arrived at the facility on 03/09/2023 and their admission agreement was signed on 03/16/2023 by a responsible party.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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 6
Control Number 22-AS-20230613154512
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: 04/15/2024
NARRATIVE
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Per R1’s physician report dated 01/12/2023 R1 was diagnosed with Cerebral vascular accident and a secondary diagnosis of chronic kidney disease. R1 was not noted to have any mild cognitive impairment or dementia and is noted to be able to communicate needs and follow directions.

It was reported on 05/08/2023 R1 was taken to the hospital due to chronic pain and returned home on 05/06/2023 with diagnosis of abnormal suputum. On 06/05/2023 it was reported on an Unusual Incident/Injury report dated 06/07/2023 that on 06/05/2023 R1’s son took them to the hospital due to complaints of R1 being lethargic and R1 was admitted to the hospital for further evaluation. Based on witness interviews R1 was diagnosed with pneumonia. It was reported by 2 witnesses that facility staff told family to not take R1 to the hospital as R1 was on hospice, R1’s family decided to take him to the hospital anyway. Based on interviews with 2 out of 2 staff indicate they did notify family that R1 was on hospice and by taking the resident to the hospital it would discontinue their hospice.

Per review of hospice agreement R1 signed the documentation to enroll in Helius Hospice on 03/26/2023, based on the evaluation listed on the hospice documentation it stated that R1 had less than 6 months, which was not reflected in the physician’s report dated 01/12/2023. It was reported by witnesses that R1 was signed up for hospice by facility representative and not by the resident or resident’s responsible party. Licensee/Administrator Brevet Dao denies this allegation.

Based on review of documentation from hospice Helius Hospice, LPA observed the documents to be incomplete and did not contain a plan of care.

Therefore, based on the preponderance of evidence through records reviewed and observation the allegations facility tried to prevent resident from being taken to the hospital by family, facility staff decided resident should be on hospice and facility did not keep accurate resident records the allegations 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20230613154512
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: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87465(g)
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(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Licensee/Administrator Brevet agreed to conduct an inservice training for 911 procedures and to provide proof by POC due date.
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This requirement was not met as evidence facility told R1's family that he was on hospice and would be discontinued. This poses an immediate health and safety risks to person in care.
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Type A
04/16/2024
Section Cited
CCR
87633(a)(3)
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(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician..., to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:
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Licensee/Administrator agreed to review hospice regulations and provide proof that it was understood by POC due date.
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(3) Hospice agency services are contracted for by each terminally ill resident.. not by the licensee on behalf of a resident or prospective resident...This requirement was not met as evidence by Licensee signed up resident for hospice. This poses an immediate risk 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: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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
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
06/13/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230613154512

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: DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Brevet Dao - Adminstrator/Licensee TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
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Facility staff did not notify resident's family of change in resident's condition.
Facility staff did not prevent resident from sustaining pressure injuries.
INVESTIGATION FINDINGS:
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2
3
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5
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted an granted entry into the facility by Administrator/Licensee Brevet Dao and explained the reason for the visit.
The Department received a complaint on 06/12/2023 and LPA Mendivil conducted the initial 10 day visit on 06/15/2023. LPA Mendivil interviewed staff and residents and obtained copies of pertinent documents such as physician report, hospice documentation and admission agreement. Regarding the allegations facility staff did not notify resident’s family of change in resident’s condition and facility staff did not prevent resident from sustaining pressure injuries, the investigation revealed the following:
The Department received an Unusual Incident/Injury Report (LIC 624) on 05/08/2023 which reported that on 05/08/2023 Resident 1 (R1) was taken to the hospital due complaints of pain and family was notified and another LIC 624 was received on 06/06/2023 stating that R1 was taken to the hospital by family. Based on interviews with Licensee/Administrator Brevet Dao they informed R1’s family when there was a change of condition.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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-20230613154512
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: 04/15/2024
NARRATIVE
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Based on interviews with 2 out of 5 residents, they indicated R1 was moved to his wheelchair to go outside and smoke cigarettes and was moved into the living to watch TV. Per review of R1’s physician report R1 has a history of skin breakdown, but 2 out of 2 staff deny seeing pressure injuries.

Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations staff did not notify resident’s family of change in resident’s condition and facility staff did not prevent resident from sustaining pressure injuries are 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: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20230613154512
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: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87633(a)(4)
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(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician..., to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:
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Licensee to review hospice regulations and provide proof to LPA by POC due date.
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(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident.. This requirement was not met as documents were not complete.
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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: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6