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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:46:30 AM

Document Has Been Signed on 09/26/2024 11:46 AM - 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:IRIS GUEST HOMEFACILITY NUMBER:
306005722
ADMINISTRATOR/
DIRECTOR:		DAO, BREVETFACILITY TYPE:
740
ADDRESS:2702 N BERKELY STTELEPHONE:
(714) 310-4436
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 6DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:50 AM
MET WITH:Brevet DaoTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Iris Guest Home. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which 1 may be bedridden. Facility has an approved hospice waiver for 5 residents and the home currently has 4 residents on hospice. Administrator/ Licensee Brevet Dao arrived during the visit. Administrator Jean Veracruz has an administrator certificate valid until 06/01/2026.
LPA Lyman along with Caregiver Norbi Banggalat toured the facility at 8:25 AM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. The home consists of three resident bedrooms, 2 common restrooms, one staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed a closet threshold in disrepair in room #3. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured 103.1 degrees F in one common restroom. At 8:40 AM, LPA is unable to measure water temperature in second common restroom as the sink is overflowing with water. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Auditory exit alarms are turned off during today's visit. First aid kit had all the elements including thermometer, tweezers and scissors as well as a first aid manual. LPA observed toxins are secured during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA tested smoke detectors during today's visit. Smoke detectors in room #1 and the hallway are non-operational. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating for residents. At 8:45, LPA observed back exit gate does not easily open. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan and plan is thorough and complete. CONT ON LIC809-C DATED 09/26/2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: IRIS GUEST HOME
FACILITY NUMBER: 306005722
VISIT DATE: 09/26/2024
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Facility provided documentation of last fire drill conducted on 07/06/2024. Facility provides activities in the form of exercise, and karaoke. At 9:30 AM, LPA reviewed six resident files and four staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Resident 1 (R1) does not have a physician order on file for half bed rails. Staff files reviewed contained required documentation of medical clearance/ TB, CPR training and criminal record clearance as well as required training. At 10:15 AM, LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 09/26/2024 11:46 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/26/2024 at 10:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed 2 smoke detectors are not working, closet threshold is in need of repair, back right burner is inoperable and water is backing up in second restroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee to repair/ replace items and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87303(e)(2)
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA tested water temperature in one restroom at 103.1 degrees F and was unable to test the other restroom due to sink backing up which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee to maintain water temperature between 105 and 120 degrees F in facility restrooms and forward proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/26/2024 11:46 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/26/2024 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Resident 1 does not have a physician order for bed rails which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee to obtain physician order for bed rails and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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