306005722-8-9-2026-22-AS-SHAN-DWSQ42-20260809114938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 08/07/2026
Date Signed: 08/09/2026 11:49:45 AM

Document Has Been Signed on 08/09/2026 11:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IRIS GUEST HOME		FACILITY NUMBER:	306005722
ADMINISTRATOR/ DIRECTOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	2702 N BERKELY ST		TELEPHONE:	(714) 310-4436
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY: 6		CENSUS: 4	DATE:	08/07/2026
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Jean Veracruz		TIME VISIT/ INSPECTION COMPLETED:	04:13 PM

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Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced Plan of Correction (POC) visit to Iris Guest Home on 08/07/2026 to follow up on deficiencies cited on 08/04/2026. LPA was greeted by Administrator (AD) Jean Veracruz, granted entry into the facility, and explained the reason for the visit.

LPA toured the interior and exterior of the facility and conducted a health and safety check, including all residents’ bedrooms. LPA also conducted a medication audit for all four current residents in care.

LPA verified that the deficiency cited under Title 22 Regulation section 87309(a), Storage Space, which states, “Disinfectants, cleaning solutions, poisons, firearms, and other items that could pose a danger if readily available to residents shall be stored where inaccessible to residents,” has been cleared. LPA observed that the cabinet containing chemicals, sharps, and cleaning supplies was secured and inaccessible to residents in care.

LPA verified that the deficiency cited under Title 22 Regulation section 87555(b)(26), General Food Service Requirements, which states, “Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises,” has been cleared. LPA observed that the facility maintained a sufficient two-day supply of perishable food to meet the needs of the residents in care.

Based on observations made during today’s visit, all deficiencies cited on 08/04/2026 have been cleared, and no deficiencies are being cited. An exit interview was conducted with Administrator Jean Veracruz, and a copy of this report was provided at the end of the visit.

Alisa Ortiz
Samer Haddadin
	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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