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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005722
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:01:14 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
05/11/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230511091058
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: 4DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Brevet Dao- Licensee/Administrator TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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facility does not maintain a healthful and comfortable accommodations for residents
Facility water temperature is not within regulatory temperature range
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Jean Vera Cruz and explained the reason for the visit. Administrator Brevet Dao was notified of LPA’s arrival and joined approximately at 10:40am.

The Department received a complaint on 05/11/2023 and conducted the initial visit on 05/19/2023. LPA Mendivil obtained copies of pertinent documents including but not limited to: physician orders. In regards to the allegations Facility does not maintain a healthful and comfortable accommodations for residents and Facility water temperature is not within regulatory temperature range the investigation revealed the following:
Regarding the allegation facility does not maintain a healthful and comfortable accommodations for residents, it was alleged Resident 1 (R1) was left in soiled clothing. Per physician report dated 12/14/2021 R1 is able to dress and groom self and is able to communicate needs. R1 is noted to have a diagnosis of Depression, Bipolar disorder and Parkinson’s disease.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
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 7
Control Number 22-AS-20230511091058
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: 10/17/2023
NARRATIVE
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During LPAs visit on 5/19/23 LPA Mendivil observed R1 to have stained clothing and noted a strong body odor coming from R1. Per records reviewed, R1 needs and service plan dated 12/1/22 does not address and/or note any issues with R1’s refusal and/or inability to self care for grooming needs. Per interviews conducted with facility staff, R1 will refuse to provide staff with their laundry at times. Staff reported doing laundry at minimum twice a week for residents in care and sometimes more, depending on how much laundry there is to wash. Interviews conducted with 4 of 4 residents could not corroborate the allegation. R1 reported their laundry is clean after staff wash their clothes and reported they have enough clean clothing. Although R1 at times will refuse to participate in meeting own hygiene needs, it does not appear that the facility did not maintain a healthful and comfortable accommodations for residents. Therefore, based on preponderance of evidence, the allegation has been determined to be Unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

It was alleged the facility water temperature is not within regulatory temperature range. During LPA’s visit dated 09/26/2023 LPA tested hot water temperature in bathroom 1 and observed the hot water to be 110 degrees F. Facility does not maintain a hot water temperature log. Per interviews with residents, residents reported the water to be ice cold. Staff denied knowledge of issues regarding hot water. Therefore, based on preponderance of evidence, the allegations has been determined to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit.

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

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
05/11/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230511091058

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: 4DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Brevet Dao- Licensee/Administrator TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is using full bed rails without physician orders
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Jean Vera Cruz and explained the reason for the visit. Administrator Brevet Dao was notified of LPA’s arrival and joined approximately at 10:40am
The Department received a complaint on 05/11/2023 and conducted the initial visit on 05/19/2023. LPA Andrea Mendivil obtained copies of pertinent documents including but not limited to: physician orders. In regard to the allegation Facility is using full bed rails without physician orders the investigation revealed the following:
It was alleged the facility is using full bed rails without physician orders. During the investigation, LPA observed Resident 2 (R2) to have half bed rails. Upon review of R2’s physician orders, no order could be found for half bedrails. LPA further observed Resident 3 (R3) to have half bedrails. Upon review of R3’s file, R3 was observed to have physician orders on file for half rails.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20230511091058
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: 10/17/2023
NARRATIVE
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During LPA’s initial visit, no residents were observed to have full bedrails.

Therefore, based on the preponderance of evidence gathered, We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit was conducted and a copy of this report was provided to facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
05/11/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230511091058

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: 4DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Brevet Dao- Licensee/Administrator TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
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9
Facility's shower drain is in disrepair
Facility is using half bed rails without physicians orders
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Caregiver Jean Vera Cruz explained the reason for the visit. Administrator Brevet Dao was notified of LPA’s arrival and joined approximately at 10:40am.
The Department received a complaint on 05/11/2023 and conducted the initial visit on 05/19/2023. LPA Andrea Mendivil obtained copies of pertinent documents including but not limited to: physician orders. In regards to the allegations Facility's shower drain is in disrepair and Facility is using half bed rails without physicians orders the investigation revealed the following:
It was alleged facility’s shower drain is in disrepair. During LPA’s initial visit on 5/19/23 LPA Mendivil observed shower in bathroom 1 to be draining slow resulting in water pooling. Following LPA’s initial visit facility Administrator Brevet Dao reported the facility drain was fixed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20230511091058
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: 10/17/2023
NARRATIVE
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It was alleged the Facility is using half bed rails without physician orders. During the investigation, LPA observed Resident 2 (R2) to have half bed rails. Upon review of R2’s physician orders, no order could be found for half bedrails. LPA further observed Resident 3 (R3) to have half bedrails. Upon review of R3’s file, R3 was observed to have physician orders on file for half rails. During LPA’s initial visit, no residents were observed to have full bedrails.

Therefore, based on the preponderance of evidence gathered, the allegations that Facility is using half bed rails without physicians orders and Facility's shower drain is in disrepair are determined to be Substantiated.

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

An exit interview was conducted with Administrator and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit.

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

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20230511091058
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: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2023
Section Cited
CCR
87608(a)(3)
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87608(a)(3) (a) Postural Supports. Based on the individual's preadmission appraisal, and subsequent changes to that appraisal,...(3) A written order from the physician indicating the need for the postural support shall be maintained in the resident's record.
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Licensee previously removed R2's bedrails and currenlty R2 is no longer at the facility.
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This requirement was not as evidence by R2 did not have physician's orders for half bed rails. This poses an immediate health and safety risk to persons in care.
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Type B
10/23/2023
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee corrected issue after visit on 05/19/2023.
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This requirement was not met as evidence by LPA observed drain in bathroom 1 to have pooling when water was ran. This poses a potential 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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7