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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005722
Report Date:
10/17/2024
Date Signed:
10/17/2024 03:01:58 PM
Document Has Been Signed on
10/17/2024 03:01 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
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
IRIS GUEST HOME
FACILITY NUMBER:
306005722
ADMINISTRATOR/
DIRECTOR:
DAO, BREVET
FACILITY TYPE:
740
ADDRESS:
2702 N BERKELY ST
TELEPHONE:
(714) 310-4436
CITY:
ORANGE
STATE:
CA
ZIP CODE:
92865
CAPACITY:
6
CENSUS:
6
DATE:
10/17/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:
Edwin Maristela and Lady Jean Bera Cruz
TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and William Vanegas conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 09/26/2024. LPA's were greeted and granted entry into the facility and explained the reason for the visit.
At 2:10PM LPA's toured the facility and observed the following:
Deficiency cited under Title 22 Regulation 87608(a)(3) pertaining to postural supports has been cleared. LPA's observed physicians order for bed rails for all resident's noted in 809. Licensee has complied with the POC.
Deficiency cited under Title 22 Regulation 87303(a) pertaining to maintenance and operation has been cleared. LPA's observed all noted items in 809 to be repaired. Licensee has complied with the POC.
Deficiency cited under Title 22 Regulation 87303(e)(2) pertaining to water temperature has been cleared. LPA's tested water temperature to be 109.2 F degrees. Licensee has complied with the POC.
Licensee addressed all items on advisory note issued on 09/26/2024.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Armando J Lucero
LICENSING EVALUATOR NAME
:
William Vanegas
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/17/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2024
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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