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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004805
Report Date: 03/20/2023
Date Signed: 03/20/2023 01:42:44 PM

Unsubstantiated


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
02/05/2021 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210205142629
FACILITY NAME:BLUE JASMINE VILLAFACILITY NUMBER:
306004805
ADMINISTRATOR:CHAVOSHPOUR, KAVEHFACILITY TYPE:
740
ADDRESS:18 SEQUOIA TREE LANETELEPHONE:
(949) 350-2338
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:6CENSUS: 4DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Parinaz SafariTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident was overmedicated while in care resulting in overdose.
Facility obtained medications for resident without authorization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed met with Staff Parinaz Safari to discuss the complaint findings for the above allegations. Administrator Kevin Chavoshpour was not able to come to the facility. The investigation consisted of interviews with staff, Resident #1(R1), Administrator as well as witnesses. Records from the facility and the hospital were also reviewed. The following was determined:

The Department received a complaint regarding allegations that Resident #1 (R1) was overmedicated while in care resulting in overdose and that the facility obtained medications for resident without authorization.

(R1) was admitted into the facility on November 4, 2020. R1 had chronic pain and was prescribed multiple opiate pain medications. On February 2, 2021 at approximately 11:15 am, R1 became lethargic and 911 was contacted by facility staff. R1 presented at the ER with an altered mental status and sepsis due to an acute UTI with fecal impaction. Narcan was given.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
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 2
Control Number 22-AS-20210205142629
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: 03/20/2023
NARRATIVE
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According to hospital records dated February 2, 2021, page 92 of Hospital History and Physical, the cause of R1’s altered mental status involved a number of factors. “The first was likely due to polypharmacy, however, it was also aggravated by the UTI and fecal impaction. It was unclear how much medication R1 actually had been getting from the board/care facility.”

Records and interviews disclosed that R1 was getting prescriptions from two different Doctor’s. According to text messages provided between the responsible party and the Licensee, the responsible party was aware of the doctor’s and pharmacy used by the facility.

Based upon interviews and a review of R1's records, these allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Parinaz Safari and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2