306004805-10-21-2022-22-AS-CDPO-CKETW6-20221021150500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004805
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:05:08 PM

Document Has Been Signed on 10/21/2022 03:05 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:	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: 3	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Facility Administrator - Kaveh Chavoshpour		TIME COMPLETED:	03:20 PM

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	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty/facility administrator Parinaz "Naz" Safari who checked temperature prior to entering facility. During the visit, 1 staff was on duty, who also contacted facility administrator (AD) Kaveh Chavoshpour about visit. As of 10/21/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed at the main entrance. LPA De Perio observed the Administrator's Certificate for Kaveh Chavoshpour, which expires on 3/6/23, Parinaz Safari, which expires on 1/20/24 and Zahrabigom Fakhim which expires on 11/6/23. LPA De Perio toured the interior and exterior portions of the facility with AD Safari. The facility is a single level structure and is licensed for 6 non-ambulatory residents 60 years and over, of which 6 may be bedridden and there is a hospice waiver for 4. For this visit, there are a total of 3 residents in care, 0 on hospice, and 0 bedridden. There are a total of 4 bedrooms, of which 1 is a private resident room, and 2 shared resident room and 1 room for staff. Per interview with AD Chavoshpour, although facility is licensed for 6, facility only plans on accepting a maximum of 5 residents. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms of which 1 is for staff and 1 is for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 108.3 degrees Fahrenheit and hand washing signs were also posted in each restroom.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2022

NARRATIVE

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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care, and is located in a kitchen cabinet. Fire extinguisher was charged, mounted and located in the garage.

LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components, and is mounted on the living room wall. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in the garage and is inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents in care and is located in the garage. Garage is also locked at all times.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates on one side of the facility, which were observed to self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Chavoshpour.

LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2022

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LPA De Perio discussed with AD Chavoshpour to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Chavoshpour.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Chavoshpour to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Chavoshpour and a copy of this report and copies of the regulations discussed were 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: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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