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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 09/10/2024
Date Signed: 10/11/2024 01:44:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
08/14/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20240814101419
FACILITY NAME:JADE GUEST HOMEFACILITY NUMBER:
306006062
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2710 N. BERKELEY STTELEPHONE:
(714) 333-5363
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 3DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Brevet Dao, AdminsitratorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Licensee is not ensuring that a separate, complete, and current record is
maintained for resident in care.
Staff do not respond to requests for communication regarding resident in
care in a timely manner.
INVESTIGATION FINDINGS:
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(This is an amended report.)
This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Leonor Gamolo, Caregiver. LPA met with Administrator Brevet Dao via phone call and explained the nature of the inspection to her and staff.
The department received a complaint on 8/14/2024 alleging Licensee is not ensuring that a separate, complete, and current record is maintained for resident in care and Staff do not respond to requests for communication regarding resident in care in a timely manner. During the investigation, the department interviewed facility Administrator (AD) and staff.
On 8/23/2024 LPA conducted a visit to the facility to initiate investigation into the above allegations. LPA obtained copies of the personnel report and resident census. LPA also obtained electronic copies of all records the facility has on file for R1.
(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
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-20240814101419
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JADE GUEST HOME
FACILITY NUMBER: 306006062
VISIT DATE: 09/10/2024
NARRATIVE
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This is an amended report. (continued from LIC9099) LPA conducted interviews with AD and Staff (S1). AD and S1 stated R1 passed away and that R1’s file is being maintained at the Administrative Office. LPA reviewed R1’s records electronically. LPA observed a Death Report for R1 dated 8/17/2024. LPA determined they would not be able to conduct interview with R1. Based on record review, LPA determined, R1's social security number was not listed on any of the documentation in R1's provided files.

On 10/9/2024, LPA conducted interview with facility's Ombudsman (OM). OM stated that, while at the facility on 8/12/24 they requested to see R1's hospice records. OM stated that the records were not produced during their visit and they did not receive a follow-up contact. LPA conducted interview with AD. AD stated that they spoke to OM over the phone on 8/12/24 and stated the file should be at the facility. AD stated they did not follow up with staff or OM. On 10/11/2024, LPA Mason returned to the facility. LPA conducted interviews with AD, staff (S1, S2) and Hospice Provider (HP). AD stated the resident was unable to communicate the social security number to facility. Staff stated they don't oversee the completion of documentation like that. HP stated they have record of R1's social security number.

Regarding the allegation of: Licensee is not ensuring that a separate, complete, and current record is
maintained for resident in care, based on interviews conducted and records reviewed, LPA determined R1’s file does not include a social security number. Title 22 Regulations state: "87506(b) Each resident’s record shall contain at least the following information: (2) Social Security number." Regarding the allegation of: Staff do not respond to requests for communication regarding resident in care in a timely manner, based on interviews conducted, OM stated that while at the facility, they requested R1's hospice file and did not receive the file or any follow-up communication. AD stated they were able to recall OM's request. AD also stated they did not follow-up with staff or OM to ensure OM received the records requested. Title 22 Regulations state: "87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately."

The preponderance of evidence standard has been met. The allegation of Licensee is not ensuring that a separate, complete, and current record is maintained for resident in care is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
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