306006062-3-21-2025-22-AS-SSAS-DF4RFL-20250325125915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 03/21/2025
Date Signed: 03/21/2025 03:43:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
12/30/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241230110812

FACILITY NAME:	JADE GUEST HOME		FACILITY NUMBER:	306006062
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	2710 N. BERKELEY ST		TELEPHONE:	(714) 333-5363
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 4	DATE:	03/21/2025
		UNANNOUNCED	TIME BEGAN:	02:46 PM
MET WITH:			TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff yelled at resident in care.

Staff did not ensure the facility was free of pests.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the two allegations listed above as well as to deliver findings to the licensee. LPA was greeted and granted entry by facility caregivers after introducing himself and stating the purpose of the visit. Administrator Jean Veracruz was notified of the visit and assisted.

An initial investigation visit was conducted by licensing staff on January 6, 2025. LPAs accompanied by facility staff toured the facility's physical plant. There were four residents in care, all of which are receiving hospice care. LPAs requested and reviewed resident records for all four residents as well as for a recently deceased resident. Two staff interviews and one resident interview conducted during the visit.

During the present visit, LPA conducted an additional tour of the premises and two staff interviews. Additional witness interviews conducted via telephone during the investigation.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20241230110812

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JADE GUEST HOME	FACILITY NUMBER: 306006062
	VISIT DATE: 03/21/2025

NARRATIVE

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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff yelled at resident in care, the following has been concluded: Based on observation conducted during the facility visits as well as on the interviews conducted with staff, residents and witnesses, there was no stated occurrence of yelling or inappropriate verbal interactions confirmed. One interviewee stated that they believed staff efforts to communicate with a specific resident with hearing impairment may have been interpreted to be yelling but denied any perceived inappropriate or abusive intent.

Regarding the allegation that Staff did not ensure the facility was free of pests, the following has been concluded: Both observations conducted failed to evidence any signs of an infestation being present. A wide majority of statements gathered denied any direct observation or suspicion of the presence of rodents and/or insects on the premises.

As a result and based on the evidence gathered, both allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

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