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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 05/15/2024
Date Signed: 05/15/2024 08:25:06 PM

Document Has Been Signed on 05/15/2024 08:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
306005722
ADMINISTRATOR/
DIRECTOR:		DAO, BREVETFACILITY TYPE:
740
ADDRESS:2702 N BERKELY STTELEPHONE:
(714) 602-7911
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 4DATE:
05/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:01 PM
MET WITH:Gemma Wanawan, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:28 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced case management visit in conjunction with complaint control #22-AS-20201229142426. LPA Quiroz was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz called and spoke to Licensee/Administrator (L/AD) Brevet Dao via telephone and explained the reason for the visit.

During today's visit while conducting inspection tour of the facility, on or about 2:50pm, LPA Quiroz observed recording monitor in Resident's 1 bedroom. On or about 3:07pm, LPA Quiroz observed monitor in bedroom area displaying picture and recording of Resident 1. This was verified with CG1 who indicated "Yeah, the AD put it there so we can see what R1 is doing when we're busy out here in the living-room and at night we put it in the bedroom so we can see the resident at all times." LPA Quiroz did not observe sign of recording in progress taking place in R1s bedroom.

On or about 3:10pm, LPA Quiroz observed Resident's 2 family in living room area where R1's recording was being displayed.

The facility is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted with CG1 and L/AD Brevet Dao via telephone and a copy of this report, appeal rights and LIC 811- Confidential names were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2024 08:25 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 05/15/2024 at 03:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...CONTINUED
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Recording camera removed during today's visit. L/AD Dao and Caregivers agreed to not use recording devices in residnent's bedroom areas. L/AD agreed to read and submit proog of understanding for CCR 87468.1 by POC due date of 5/22/024.
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This requirement is not met as evidenced by:During today's visit while conducting inspection tour of the facility, on or about 2:50pm, LPA Quiroz observed recording monitor in Resident's 1 bedroom. On or about 3:07pm, LPA Quiroz observed monitor in bedroom area displaying CONTINUED
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picture and recording of Resident 1. This was verified with CG1 who indicated "Yeah, the AD put it there so we can see what R1 is doing when we're busy out here in the living-room and at night we put it in the bedroom so we can see the resident at all times." This poses a potential risk to residents 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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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