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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 04/15/2024
Date Signed: 04/15/2024 02:20:09 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
08/07/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230807135753
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: DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brevet Dao - Adminstrator/Licensee TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff failed to provide adequate care and supervision, resulting in injury
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 the facility by Administrator/Licensee Brevet Dao and explained the reason for the visit.
The Department received the complaint on 08/07/2023 and LPA Quiroz conducted the initial 10-day visit on 08/15/2023 and LPA Mendivil conducted a follow up visit on 03/27/2024. LPA Mendivil interviewed staff and was unable to interview residents as all were asleep at the time of the visit. LPA Mendivil obtained copies of documents such as admission agreement and physician’s report. Regarding the allegation Facility staff failed to provide adequate care and supervision, resulting in injury, the investigation revealed the following:
Per review of Resident’s 1 (R1) documentation R1 arrived at the facility on 07/26/2023. Based on R1’s physician report dated 07/2023 it was noted that R1 is diagnosed with hypertensive heart disease with heart failure, it is also noted that R1 needs assistance with all activities of daily living. Per physician’s report R1 did not have a history of skin breakdown.
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: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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 2
Control Number 22-AS-20230807135753
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: 04/15/2024
NARRATIVE
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Based on interviews with staff R1 was withdrawn and wanted to remain in bed. It was reported by Administrator/Licensee Brevet Dao that R1 left the facility 08/02/2023. Interviews with 2 out of 2 staff indicate they did not see any pressure injuries in the 7 days that R1 was at the facility. LPA Mendivil was unable to reach hospice for further records.

Therefore, based on the preponderance of evidence through records reviews and interviews the allegation facility staff failed to provide adequate care and supervision, resulting in injury the allegation is 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 was provided to facility Administrator.

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

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2