<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 09/16/2025
Date Signed: 09/16/2025 10:55:19 AM

Substantiated


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
09/14/2025 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250914154018
FACILITY NAME:JADE GUEST HOMEFACILITY NUMBER:
306006062
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2710 N. BERKELEY STTELEPHONE:
(714) 333-5363
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 4DATE:
09/16/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Lady Jean Vera CruzTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly transfer resident's personal belongings.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Administrator Lady Jean Vera Cruz.

During the course of the investigation LPA toured facility, reviewed records, conducted staff interviews, made visual observations, documented photos of belongings and requested pertinent documentation such as Admission agreement, resident personal property and valuables and emergency identification form.
During investigation LPA reviewed facility records such as resident admission agreement dated March 17, 2024, which noted under “Belongings Removal” section, “In the event of resident vacating premises, facility will make reasonable efforts to assist resident or responsible person with belongings removal. Facility requires all resident personal belongings to be removed as quickly as responsible party can”. LPA also reviewed Resident’s Personal property and Valuables form noting Resident 1 to have four long sleeve shirts and four jogging pants.
CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
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 3
Control Number 22-AS-20250914154018
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: 09/16/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During investigation LPA observed, facility had a box secured inside garage with Resident 1’s personal belongings. LPA Tirre observed the box to have 10 clothing shirts/ Jacket, a bag of slippers and a bag of socks & underwear. After conducting interview with staff, LPA inquired if there were any additional belongings of R1 to which LPA observed facility to have R1’s mail, ATM card and checkbook.

Per Investigation interviews three of three staff confirmed R1 left facility via ambulance on June 30, 2025. Per interviews with staff, two of three staff members stated that R1 left facility due to being a fall risk due to a recent change in condition. Per staff interviews R1 required a higher level of care and was transported to a hospital and then transported to a Skilled Nursing Facility. Per staff interviews, two of three staff stated that A Coordinator from Skilled Nursing Facility was to pick up R1’s belongings but as of today’s date September 16, 2025 had not picked up items.

Based on records reviewed, observations and interviews conducted the preponderance of evidence has been met. The following deficiencies are being cited per Title 22.



An exit interview was conducted with Administrator Lady Jean Vera Cruz and a copy of this report, along with confidential names list and appeal rights was reviewed and provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250914154018
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2025
Section Cited
CCR
87217(i)
1
2
3
4
5
6
7
**AMENDED REPORT** Safeguards for resident cash, personal property & valuables. Upon discharge of a resident ,all cash resources, personal property & valuables, of that resident...shall be surrendered to resident or responsible person. A signed receiprt shall be retained. Based on investigation this requirement was not met as evidenced by
1
2
3
4
5
6
7
As plan of correction (POC) , Facility is to coordinate and transfer R1’s belongings with new facility. Facility to provide proof of transfer by having a signed document from facility representative by POC due date 9/23/25.
8
9
10
11
12
13
14
facility failed to transfer personal belongings in a timely manner. R1 has been out of facility since 6/30/25. This poses a potential health & safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3