306004805-3-16-2023-22-AS-LADS-CQ8PC4-20230324111117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:06:51 PM

Unfounded

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
12/16/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221216090339

FACILITY NAME:	BLUE JASMINE VILLA		FACILITY NUMBER:	306004805
ADMINISTRATOR:	CHAVOSHPOUR, KAVEH		FACILITY TYPE:	740
ADDRESS:	18 SEQUOIA TREE LANE		TELEPHONE:	(949) 350-2338
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	6	CENSUS: 4	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Facility Administrators - Kaveh Chavoshpour and Parinaz “Naz” Safari		TIME COMPLETED:	01:17 PM

ALLEGATION(S):

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Facility has not provided POA with requested documentation
Facility does not communicate with POA
Facility not billing properly
Resident bedrooms doors have a lock that required a code

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrators, Kaveh Chavoshpour and Parinaz “Naz” Safari and stated the purpose of this visit which was to deliver the final findings for the complaint received on 12/16/22 against this facility.

For today’s visit, there are a total of 4 residents in care of which 1 is on hospice.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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-20221216090339

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: BLUE JASMINE VILLA	FACILITY NUMBER: 306004805
	VISIT DATE: 03/16/2023

NARRATIVE

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The Department has investigated the complaint alleging that facility has not provided Power of Attorney (POA) with requested documentation. Per documentation reviews and interviews conducted by LPA, it was found that facility did provide POA with the requested documentation on 1/8/23 and 1/12/23, specifically, regarding the resident’s medication record for November 2022-December 2022. The information was sent via text message, and the medication record for December 2022 was provided in person to the POA, Ombudsman, and faxed to the POA’s preferred doctor. Based on interviews and review of records obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

The Department has investigated the complaint alleging that facility does not communicate with POA. LPA conducted interviews and documentation reviews and found that facility and POA communicate in person, through verbal conversation, through text messages, and email. LPA also conducted additional interviews with responsible parties of current residents and of residents who have previously lived at the facility, all of which stated that the facility does communicate with the POA either via verbal conversation or via text message. LPA conducted a total of 8 interviews and 6 out of the 8 interviews conducted all reported that facility communicates with POA via verbal conversation, via phone call or text, or email and the 2 remainder of interviews did not corroborate with the allegation due to unavailability, and unable to provide further information regarding this allegation. Based on the interviews conducted and documentation obtained, the Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221216090339

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: BLUE JASMINE VILLA	FACILITY NUMBER: 306004805
	VISIT DATE: 03/16/2023

NARRATIVE

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The Department has investigated the complaint alleging that facility is not billing properly. LPA conducted interviews and documentation reviews and found that the facility is in partnership with the Assisted Living Waiver (ALW) Program, of which part of the financial aspect of the resident paying for a facility goes through ALW. On 11/8/22 and 12/15/22, the facility sent a notice that the responsible party is withholding the payment for the month of December 2022 due to feeling as if there was an overcharge. It was verified by the ALW Director on 1/4/23, that the facility had not been overcharging the resident and that the amount the resident has been charged in December 2022, is correct. On 12/23/23, the facility verified with responsible party that the payment amount was correct and on 1/26/23, an itemized list was issued to show for the breakdown of expenses, and in January 2023, the resident still had an unpaid balance that was owed. Per review of the documents provided by the ALW Director, and confirmation that the amount was correct, the responsible party owed a total of $1,365.77 for the month of December. In addition, it was found that in the facility admission agreement, the facility will provide incontinence supplies which would cost and extra $150.00, and upon the resident being admitted to the facility, the responsible party denied incontinence supplies and instead, would provide it to the facility. However, as resident started to progress in condition, and began to need incontinence supplies, the responsible party did not pay for it. It was stated that per facility admission agreement, if a resident needed incontinence supplies, the responsible party had the option to either accept the terms, meaning that the facility will pay for the supplies, of which that fee will be included in the monthly statement, or deny the terms, of which the responsible party will separately pay and supply the facility and resident with the incontinence. On 2/6/23, ALW director verified the amount again and stated that the fees were correct. Per LPA’s review of the signed admission agreement, it was determined that the responsible party denied this portion of the facility admission agreement. Based on the interviews conducted and documentation obtained, the Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20221216090339

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: BLUE JASMINE VILLA	FACILITY NUMBER: 306004805
	VISIT DATE: 03/16/2023

NARRATIVE

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The Department has investigated the complaint alleging that resident bedroom doors have a lock that required a code. LPA conducted interviews, record reviews and toured the facility and it was found that there are only three locks in the following locations of the facility: the door leading to the garage, the caregiver room, and one resident room. Per interviews with the residents residing in the room with the lock, both residents requested for the lock to be in place. LPA conducted a total of 6 interviews of which 4 corroborated with the allegation, 1 was unavailable for an interview, and 1 was unable to continue with the interview. LPA reviewed charts of both residents whose door has a lock, and found that both residents do not have any cognitive impairment. The code to the lock is also labeled on the lock, and residents are able to open the door without a lock from the inside of their room. LPA also verified that there is no lock from inside the resident’s bedroom, only on the outside door. Based on the interviews conducted and documentation obtained, the Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

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

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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