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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:58:32 PM

Substantiated


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
09/20/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230920162715
FACILITY NAME:IRIS GUEST HOMEFACILITY NUMBER:
306005722
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2702 N BERKELY STTELEPHONE:
(714) 602-7911
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ben Briones - Caregiver TIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Administrator is evicting residents without a written notice
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Caregiver Ben Briones and explained the reason for the visit.

The department received a complaint on 09/20/2023 and LPA Mendivil conducted the initial 10 day visit on 09/21/2023. During the course of the visit LPA Mendivil interviewed staff, residents and a witness. Regarding the allegation administrator is evicting residents without a written notice, the investigation revealed the following:

Based on interivews with residents 2 out of 3 residents stated they were told on the morning of 09/20/2023 that they were going to be evicted and needed to relocate due to renovations. Interviews with 2 out 3 residents indicated they were offered a room at another licensed facility and were given 1 day to decide if they wanted to move to the other licensed facility. CONT on LIC 9099-C dated 09/21/2023
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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 3
Control Number 22-AS-20230920162715
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: IRIS GUEST HOME
FACILITY NUMBER: 306005722
VISIT DATE: 09/21/2023
NARRATIVE
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Based on interviews with 2 out 3 residents indicated after they contacted their advocates the administrator provided an eviction notice around 6pm on 09/20/2023. Based on interviewers with residents 1 resident was not given the eviction notice and instead it was placed inside of the locked medicine cabinet and had to ask for the caregiver to provide the form. The 3rd resident would not answer LPA Mendivil's questions. Based on interviews with witnesses indicate the residents told them they felt like they were being evicted and given no option but to move the other licensed facility.

Per interviews with Administrator Brevet Dao, Administrator Dao stated she did not give residents an ultimatum to move to another facility, but felt that she was providing residents with options. Administrator Dao stated she did not provide the written notices until after residents were informed verbally.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegation Administrator is evicting residents without a written notice is SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

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

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230920162715
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: IRIS GUEST HOME
FACILITY NUMBER: 306005722
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2023
Section Cited
CCR
87224(a)(5)(A)
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(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). ...
(5) Change of use of the facility.
A) The licensee may, upon no less than sixty (60) days written notice...
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Licensee provided written eviction notice to residents.
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... evict a resident due to change of use of the facility. This requirement was not met as evidence by Administrator verbally told residents they needed to relocate due to eviction. This poses a potential health and safety risk to persons in care.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3