306006062-1-27-2023-22-AS-SSAS-CNL52H-20230130183420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:07:59 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
01/17/2023 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20230117133658

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: 6	DATE:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ben Briones		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Facility did not accompany resident to a medical appointment
Facility has insects.
Facility did not seek medical treatment for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst Michelle Reed arrived at the facility to discuss the complaint allegations. Upon arrival, LPA met with Ben Briones Mr. Briones informed LPA that R1 did not reside at this facility. He resided at 2702 Berkeley St. which is the sister facility in front named Iris Guest Home. The homes share the same property and structure but have two different addresses.

Based upon interview with Mr. Briones these allegations are unfounded at this facility, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. R1 never lived at this facility.

An exit interview was conducted and a copy of this report was given to Ben Briones. Allegations will be investigated at Iris Guest Home #306005722.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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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