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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:57:56 PM

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
10/26/2022 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221026135817
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: 5DATE:
04/25/2023
UNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Teres De Pilar - Caregiver TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff lack emergency disaster training
Facility does not have emergency oxygen
An uncleared individual is living in facility
Facility failed to maintain temperature within regulatory requirements
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in order to deliver complaint findings. LPA was greeted and granted entry into the facility by Teresa De Pilar and explained the reason for the visit.

The Department received a complaint on 10/26/2022 and conducted the initial visit on 10/31/2022. LPA Mendivil obtained copies of pertinent documents including but not limited to: staffing documents, medication records and facility roster. In regards to the allegations facility staff lack emergency disaster training, facility does not have emergency oxygen, and An uncleared individual is living in facility, the investigation revealed the following:

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

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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 6
Control Number 22-AS-20221026135817
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: 04/25/2023
NARRATIVE
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Regarding the allegation Facility staff lack emergency disaster training, LPA reviewed five of five staff files. Of the staff files reviewed, LPA confirmed five of five staff have documentation of current emergency disaster training. Staff interviewed were able to explain the process of disaster training. LPA verified one of five staff present has a current CPR training. The remaining four of five staff have current first aid training. Therefore the allegation that facility staff lack emergency disaster training is determined to be Unfounded.

Regarding the allegation that facility does not have emergency oxygen, during the investigation LPA confirmed that facility maintained multiple spare oxygen canisters in the facility garage. LPA confirmed canisters to be full and operational. Therefore the allegation that facility does not have emergency oxygen has been determined to be Unfounded.

LPA Mendivil cross reviewed facility Personnel Summary List and all staff listed on LIC 500 (Personnel Report) and confirmed all staff listed are associated with the facility. LPA Mendivil also reviewed documentation such as, but not limited to, staff files of which all present employees were reflected as having the necessary criminal background clearance. Therefore the allegation Uncleared individual is living in the facility has been determined to be Unfounded.

For allegation facility failed to maintain temperature within regulatory requirements. Based on observations made during LPA’s visits to the facility on 10/31/2022, LPA observed the facility to be maintained at a comfortable temperature meaning residents did not appear to be over heated, sweating and/or unreasonably cold. Temperature within the facility appeared to be maintained within regulatory requirements. Therefore allegation that facility failed to maintain temperature within regulatory requirements is Unfounded.



An exit interview was conducted and a copy of this report was provided at the time of exit.

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

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/26/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20221026135817

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: 5DATE:
04/25/2023
UNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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2
3
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5
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8
9
Facility failed to address pest infestation
Facility lacks emergency lights
Resident bedrooms have insufficient lighting
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 facility by caregiver Leo Garias and explained the reason for the visit.

The Department received a complaint on 10/31/2022 and conducted the initial visit on 10/31/2022. LPA Mendivil obtained copies of pertinent documents including but not limited to: staffing documents, medication records and facility roster.In regards to the allegations facility failed to address pest infestation, facility lacks emergency lights, and resident bedrooms have insufficient lighting, the investigation revealed the following:

CONT on LIC 9099-C
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: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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 6
Control Number 22-AS-20221026135817
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: 04/25/2023
NARRATIVE
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Regarding the allegation that facility failed to address pest infestation, the Investigation determined the facility does have a pest infestation, including but not limited to roaches and rodents. During LPA’s multiple visits to the facility LPA observed multiple mouse traps along with rodent droppings in multiple resident rooms. Interviews conducted with 2 of 6 residents confirmed residents have not seen rodents in the facility, however, acknowledge seeing rodent droppings on multiple occasions. Although the facility implemented rodent traps at the facility, the facility failed to properly address the pest infestation as evidence by the on going rodent droppings visible in the facility despite having implemented rodent traps. Therefore, the allegation is determined to be Substantiated.

Regarding the allegation that the facility lacks emergency lights, the investigation determined that the facility does not have emergency lighting. Based on interview with Administrator Brevet Dao it was reported that the facility utilizes hallway and bathroom lights as lights at night. This does not constitute emergency lighting as it would not be available during a potential power outage. Therefore, the allegation is Substantiated.

For the allegation that resident bedrooms have insufficient lighting, LPA Mendivil observed 2 out of 3 resident bedrooms had missing light bulbs. It appears the facility utilizes natural light during the day and due to missing light bulbs, the facility does not have sufficient lighting for night time. Therefore, the allegation is Substantiated.
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, LIC9099-D, and appeal rights was provided at the time of exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20221026135817
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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operations: (a )The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator has provided LPA with pest control contract which is for pest control to visit facility quaterly and as needed. Retained copy on file.
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This requriement was not met as evidence by the facility had multple rodent traps, but the present of rodent droppings were still visble. This poses an immediate health and safety risk to persons in care.
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Type B
05/01/2023
Section Cited
CCR
87303(h)
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87303 (h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.
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Administrator to distrubute emergency lighting to appropiate areas.
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This requirement is not met as evidence by Administrator stated that the facility utilizes hallway and bathroom lights on at night. Facility does not have emergency lighting set up.
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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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20221026135817
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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2023
Section Cited
CCR
87307(3)(B)
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87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care ... shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
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Administrator has since replaced ceiling fan/lights.
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B) Bedroom furniture, which shall include, for each resident,.. a lamp, or lights sufficient for reading... This requirement was not met as evidence by 2 out of 3 residents bedrooms have missing light bulbs. This poses a potential 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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6