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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:14:59 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
01/16/2024 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20240116131630
FACILITY NAME:JADE GUEST HOMEFACILITY NUMBER:
306006062
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2710 N. BERKELEY STTELEPHONE:
(714) 507-8040
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 4DATE:
03/05/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brevet Dao TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident's change in condition
Staff did not reposition bedridden resident
Staff did not treat resident with dignity
Staff did not administer resident's medications as prescribed
Staff are unable to meet residents needs due to language barrier
Staff left resident in bed all day
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Melanie Geller, Caregiver and explained the reason for the visit. Administrator Brevet Dao arrived at the facility shortly after.

The Department received the complaint on 01/16/2024 and LPA Mendivil conducted the initial 10 day visit on 01/22/2024. LPA Mendivil interviewed staff and obtained copies of pertinent documents including: physician's reports, admission agreement and medication administration record. LPA Mendivil was unable to interivew residents as they were asleep during visits. Regarding the allegations staff did not seek medical attention for resident's change in condition, staff did not reposition bedridden resident, staff did not treat resident with dignity, staff did not administer resident's medication as prescribed, staff are unable to meet residents needs due to language barrier and staff left resident in bed all day, the investigation revealed the following:

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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 5
Control Number 22-AS-20240116131630
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: JADE GUEST HOME
FACILITY NUMBER: 306006062
VISIT DATE: 03/05/2024
NARRATIVE
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Per interviews with Administrator Brevet Dao Resident 1 (R1) arrived at the facility on 12/05/2023 with the diagnosis of Non-ST-Elevation Myocardial Infarction and cerebrovascular accident. Per R1's physician report listed the R1 as non-ambulatory but also notes R1 is bed bound and has motor impairment/paralysis.
It was alleged that facility staff did not seek medical attention when there was a change of condition, per review of LIC 624 Unusual Incident/Injury Report for the dates 12/08/2023 and 12/10/2023 when there was a change in condition with Resident 1 (R1) 911 was called. In both cases R1 was taken to the hospital and returned to the facility after discharge.
It was alleged that staff did not reposition bedridden resident. Per review of R1’s LIC 602 physicians’ report dated 11/15/2023 list R1 as bed bound, but not bedridden. Based on interviews with 2 out of 2 staff resident would request to stay in bed or be moved to their wheelchair. Per interview with Administrator R1 was able to reposition themselves but due to diagnosis had weakness on left side of the body.
Interviews with 2 out of 2 staff denied that they did not treat residents with dignity. Per LPA Mendivil's observations residents have access to a call button which plays an auditory sound in the living room/kitchen. Per LPA Mendivil's observations staff responded within 2 minutes.
Based on review of R1's medication administration records (MAR) for December 2023, per review medications were given as prescribed and on the days/times noted. Based on interviews with 2 out of 2 staff deny medications are not given as prescribed.
It was alleged that staff are unable to meet residents needs due to language barrier, per LPA Mendivil's observations LPA Mendivil has observed the staff to all communicate with resident's in previous visits in English and to be able to communicate effectively.
It was alleged staff left resident in bed all day, based on interviews with 2 out of 2 staff the resident would request to either stay in bed or would request to be placed in wheelchair and view outside.
Therefore, based on the preponderance of evidence through records reviewed, interviews and observations the allegations staff did not seek medical attention for resident's change in condition, staff did not reposition bedridden resident, staff did not treat resident with dignity, staff did not administer resident's medication as prescribed, staff are unable to meet residents needs due to language barrier and staff left resident in bed all day are 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.
No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/16/2024 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20240116131630

FACILITY NAME:JADE GUEST HOMEFACILITY NUMBER:
306006062
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2710 N. BERKELEY STTELEPHONE:
(714) 507-8040
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 4DATE:
03/05/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not provide adequate food service to resident
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Melanie Geller, Caregiver and explained the reason for the visit. Administrator Brevet Dao arrived at a later time.

The Department received the complaint on 01/16/2024 and LPA Mendivil conducted the initial 10 day visit on 01/22/2024. LPA Mendivil interviewed staff and obtained copies of pertinent documents including: physician's reports, admission agreement and medication administration record. LPA Mendivil was unable to interivew residents as they were asleep during visits. Regarding the allegation staff did not provide adequate food service to resident, the investigation revealed the following:
Per interviews with Administrator Brevet Dao Resident 1 (R1) arrived at the facility on 12/05/2023 with the diagnosis of Non-ST-Elevation Myocardial Infarction and cerebrovascular accident. Per R1's physician report listed R1's diet as a renal diet.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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 5
Control Number 22-AS-20240116131630
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: JADE GUEST HOME
FACILITY NUMBER: 306006062
VISIT DATE: 03/05/2024
NARRATIVE
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Per interviews with staff 1 out of 2 staff indicated they were unaware that R1 had a special diet. Based on interview with Administrator Brevet Dao there is no record of what was fed to R1 during December 2023 to prove that a renal diet was followed.

Therefore based on preponderance of evidence through interviews the allegation Staff did not provide adequate food service to resident is determined to be 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.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240116131630
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: JADE GUEST HOME
FACILITY NUMBER: 306006062
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2024
Section Cited
CCR
87555(b)(5)
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(b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidence by 1 out of 2 staff was not aware of Residents 1 special diet.
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Licensee agreed to provide in service to staff on renal diets and other possible diets that residents may have. Licensee agreed to keep a log of groceries purchased to prepare meals and provide proof to LPA by POC due date.
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This poses a possible 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5