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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 10/31/2022
Date Signed: 10/31/2022 05:10:18 PM

Substantiated


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: 6DATE:
10/31/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Brevet Dao- AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility is not maintained clean
Facility walkways are not free of hazards
Facility screens are in disrepair & missing
Facility fire alarm is in disrepair
Medications are not stored properly
Medication records are not being kept
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil and Licensing Program Manager (LPM) Alisa Ortiz along with Rafael Perez Code Compliance Supervisor, Ines Guzman Code Compliance Officer and Orange County Fire Authority Representative R. D made an unannounced visit for the purposes of conducting an investigation into the above allegations.

The investigation determined the following:At 1:41PM LPA and LPM observed nonoperational smoke alarm in the facility kitchen. At 1:44PM LPA and LPM observed unlocked medication closet in facility hallway. At 1:46PM LPA observed roach and droppings in facility kitchen drawer.
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: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
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 7
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: 10/31/2022
NARRATIVE
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 At 1:56PM LPA and LPM observed bike and discarded pictures obstructing walkway. At approximately 3:30PM LPM Ortiz and Administrator conducted a review of Resident 1 (R1) and Resident 2 (R2) medications. Per the review conducted resident's medications are not being kept. Due to insufficient documentation, it remains unclear if resident's are receiving medications as prescribed.

Based on the above information, the following allegations are deemed to be SUBSTANTIATED: Facility is not maintained clean; Facility walkways are not free of hazards; Facility screens are in disrepair & missing; Facility fire alarm is in disrepair; Medications are not stored properly; and Medication records are not being kept.

The following is being cited per California Code of Regulations Title 22 Divison 6 Chapter 8.

An exit interview was conducted and a copy of this report, confidential names list, appeal rights and civil penalty assessment was provided to the Administrator.

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

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(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.
This requirement was not met as evidence by:
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Licensee agrees to set up daily cleaning schedule and seal all openings into the home. Licensee to provide proof by POC due date 11/14/2022.
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LPA and LPM observed rodents and pest present in facility along with rodent droppings. This poses an immediate health risk to persons in care.
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Type B
11/14/2022
Section Cited
CCR
87307(d)(6)
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87307 Personal Accommodations and Services
d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement was not met as evidence by:
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Licensee agrees to remove obstructions from walkways and provide picture proof of corrections by POC due date of 11/14/2022.
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LPA observed discarded bike and paintings obsturcting walkway along side of house. LPA and LPM observed screws coming out of ground along other side patiowalkway which poses a potential health and safety 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: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited
CCR
87303(b)
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87303 Maintenance and Operation
(b) All window screens shall be clean and maintained in good repair. This is evidence by missing screen in facility ktichen slider, which poses a potential health and safety risk to persons in care.
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Licensee agrees to repair/replace broken and missing screens and provide proof of correction by POC due date of 11/14/2022.
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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: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2022
Section Cited
CCR
87203
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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This regulation was not met as evidence by:

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Licensee agrees to repair non-operational smoke alarms by POC due date of 11/01/2022
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Based on observation smoke alarm in kitchen is nonoperational and fire door leading to resident bedrooms is proped open, this poses an immediate safety risk to persons in care.
CIVIL PENALTY ASSESSED.
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Type A
11/01/2022
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked....This regulation was not met as evidence by:
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Licensee agrees to set training date for all staff regarding medication management/storing by 11/01/2022. Training is to be completed by no later than 11/14/2022 and proof of training to be sent to LPA by 11/14/2022.
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Based on observation LPA observed an unlocked medication cabinet in facility hallway.This poses an immediate health and safety 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: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2022
Section Cited
CCR
87465(h)(6)
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(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
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Licensee agrees to review all resident's medication and update record keeping. License to provide copies of updated records to LPA by COB 11/01/2022.
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Based on medication reviewed for Resident 1 and Resident 2 medications records failed to document date medication started and medications missed. It remains unclear if medications are being given as prescribed. This poses an immediate health and safety 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: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7