306006062-7-27-2022-22-AS-AJLO-CKJQ8W-20221025115725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 07/26/2022
Date Signed: 07/27/2022 08:18:44 AM

Unfounded

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
02/15/2022 and conducted by Evaluator Shobhana Frank

COMPLAINT CONTROL NUMBER: 22-AS-20220215162238

FACILITY NAME:	JADE GUEST HOME		FACILITY NUMBER:	306006062
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	2710 N. BERKELEY ST		TELEPHONE:	(714) 507-8040
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 4	DATE:	07/26/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Licensee Brevet Dao		TIME COMPLETED:	03:29 PM

ALLEGATION(S):

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Facility is not following menu
Resident complaining of hunger
No perishable food available
Personal Rights
Resident not receiving bath
Lack of qualified staff to provide care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Licensee Brevet Dao and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviews of RP, R1’s sister, staff 1 and staff 2 reviewed and obtained pertinent documentation such as Physicians report LIC 603 and Admission Agreement.
Based on the reviews of Admission Agreements, daily notes, Physician’s report LIC 602, observation revealed that R 1 is legally blind and has Dementia, does not have teeth, no dentures. Interviews of R 1, RP, R1’s sister, staff 1 and staff 2 this complaint found to be unfounded.
During the interview R 1 stated there is nothing to report, he is well taking care off by staff. Also interviewed RP stated that because of lack of communication and misunderstanding he had file a complaint. After meeting with Administrator he realized that facility is taking care of his uncle.
continue -LIC 9099 C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220215162238

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: 07/26/2022

NARRATIVE

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Facility is continued sending R1's updates. Now because of better communication having with Licensee he understands facility's operation. All good news now he don't see any problem, he have good relationship with the staff, he calls and visits his uncle often. His uncle R 1 is doing really good at the facility. R1’s sister reported that she visited R1 and is happy and thankful to licensee and caregivers providing good care of R1.

Based on the collective information, the above allegations are determined unfounded. This agency has investigated the complaint alleging (Facility is not following menu,Resident complaining of hunger,
No perishable food available, Personal Rights, Resident not receiving bath, Lack of qualified staff to provide care, We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC9099 (FAS) - (06/04)

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