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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 04/15/2024
Date Signed: 05/02/2024 04:47:39 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
09/02/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20220902153422
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: 6DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Brevet Dao - Licensee/Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Licensee does not ensure that a comfortable temperature is maintained in rooms that residents occupy.
Facility does not meet resident's dietary needs
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 Adminstrator/Licensee Brevet Dao
and explained the reason for the visit.

The Department received a complaint on 09/02/2022 and the Department conducted the initial 10 day visit on 09/08/2022. Regarding the allegations licensee does not ensure that a comfortable temperature is maintained in rooms that residents occupy, and facility does not meet resident’s dietary needs, the investigation revealed the following:

During the visit on 10/31/2022 LPA Mendivil interviewed residents present at that time indicated the facility will provide fans if the weather outside is warm. LPA Mendivil visited the facility on 05/19/2023, 5/25/2023,06/15/2023 , 07/11/2023 and 8/15/2023 and the facility was within regulatory temperatures and LPA Mendivil observed the air conditioning to be operational and on, on multiple occasions.
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: 1 of 5
Control Number 22-AS-20220902153422
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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During the visit on 10/31/2022 LPA Mendivil interviewed residents present at that time indicated the facility will provide fans if the weather outside is warm. LPA Mendivil visited the facility on 05/19/2023, 5/25/2023,06/15/2023 , 07/11/2023 and 8/15/2023 and the facility was within regulatory temperatures and LPA Mendivil observed the air conditioning to be operational and on, on multiple occasions.

Based on observations by LPA Mendivil observed the refrigerator was stocked with eggs, bread, ham, and chicken. LPA Mendivil observed a sample menu on the refrigerator. Based on interviews with Administrator Brevet Dao the menu is not always followed, and it is modified. Administrator stated they try to accommodate all resident's dietary restrictions with are mostly low sodium and low carbohydrate meals. Interviews with staff indicate that groceries are purchased every 5 days.

Therefore, based on the preponderance of evidence through interviews and observations the allegations that licensee does not ensure that a comfortable temperature is maintained in rooms that residents occupy and facility does not meet resident’s dietary needs 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.

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 5
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
09/02/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20220902153422

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:
01:46 PM
MET WITH:TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff yell at resident
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 Administrator/Licensee Brevet Dao and explained the reason for the visit.

The Department received a complaint on 09/02/2022 and the Department conducted the initial 10 day visit on 09/08/2022. Regarding the allegation staff yells at residents the investigation revealed the following:
interviews conducted with Staff 1 (S1) and Administrator Dao deny allegations of yelling. S1 confirmed they do speak in a loud voice when speaking with residents due to residents being hard of hearing. Based on the interviews that were conducted on 03/14/2023 of the resident’s present at that time., Interviews conducted with two of six residents in care confirmed that S1 does yell at residents. The remaining four residents were unavailable and/or unable to be interviewed due to communication barriers. LPA Mendivil reviewed S1’s personnel file training for personal rights was observed on file expired March 16, 2023, which was within the one year mark.
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: 3 of 5
Control Number 22-AS-20220902153422
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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Therefore based on interviews the allegation that staff yells are residents 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.

Civil Penalty assessed based on repeat violation.

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: 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: 4 of 5
Control Number 22-AS-20220902153422
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
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee to provide proof of all staff training for personal rights to LPA by due date. S1 is no longer working at the facility.
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This requirement was not met as evidence by: 2 out of 6 residents stated that S1 yells. This poses a potential risk to persons safety 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: 5 of 5