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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 07/28/2023
Date Signed: 07/28/2023 05:16:08 PM

Document Has Been Signed on 07/28/2023 05:16 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: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:
07/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Brevet DaoTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joseph Alejandre and Dwayne Mason made an unannounced case management visit (See complaint #22-AS-20230721153400 dated 7/21/23). Earlier in the day, an attempted visit was initiated earlier this morning by Department personnel which had to be ended due to safety concerns. LPAs Mason and Alejandre conducted a Health and Safety visit at the facility to ensure the safety of the residents and staff and to retrieve State equipment. LPAs were greeted and granted entry by staff and explained the reason for the visit. LPAs along with staff toured the facility and reviewed resident medications and records. LPAs observed all residents were asleep at the time of the visit. LPAs observed both resident bathrooms were clean and operational. LPA observed a 7 day non-perishable and 2 day perishable food supply on hand. LPAs observed the facility had electricity, gas and water service. During the visit the facility temperature was 79.8 degrees Fahrenheit. LPAs observed a rodent caught in a trap in the water heater closet next to the bathroom. LPAs reviewed R1's medication records. R1 was prescribed Metformin 1000 mg twice a day, Simvastin 20 mg once a day, One-Daily Multivitamin one tablet a day, and Lisinopril 10 mg once a day. A review of R1's medication administration record shows R1 was not administered any medication on June 30, 2023. LPAs observed the kitchen was clean and organized. LPAs observed the see something say something poster (PUB 475) posted in the hallway. LPAs observed the fireplace in the living room is screened. LPAs observed water leaking from a drain pipe on the outside walkway leading to the back exit gate. LPAs observed next to the back exit gate, adjacent to the garage an old chair, nightstand and a dresser. LPAs observed the cleaning supplies are kept locked under the sink. LPAs observed the knives and sharp objects are kept locked in the caregiver's room. Based on the observations made during today's visit deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and a civil penalty is being issued for a repeat violation within a 12 month period. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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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Document Has Been Signed on 07/28/2023 05:16 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 07/28/2023 at 04:26 PM
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: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2023
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not being met as evidenced by, LPAs observed a dead rodent caught in a trap in the water heater closet.
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Licensee agrees to have a professional exterminator service the facility to eliminate the rodent issue. Licensee to forward proof to LPA by POC due date.
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This poses an immediate health and safety risk to residents in care.
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Type A
07/29/2023
Section Cited
CCR87468.1(a)(16)

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To receive or reject medical care or other services. This requirement is not being met as evidenced by, a review of the medication administration record shows R1 did not receive their prescribed medications, Metformin, Simvastatin, Lisinopril and One-Daily Multivitamin on June 30, 2023.
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Licensee agrees to ensure all residents received medication as prescribed and to document all medication administered. Licensee agrees to train staff in regards to residents rights and medication administration. Licensee to submit proof to LPA by POC due date.
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This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
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