306006062-5-26-2026-22-AS-AORZ-DV425P-20260615170552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006062
Report Date: 05/26/2026
Date Signed: 05/26/2026 04:14:48 PM

Unsubstantiated

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
11/20/2024 and conducted by Evaluator Andrea Mendivil

COMPLAINT CONTROL NUMBER: 22-AS-20241120112843

FACILITY NAME:	JADE GUEST HOME		FACILITY NUMBER:	306006062
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	2710 N. BERKELEY ST		TELEPHONE:	(714) 333-5363
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 6	DATE:	05/26/2026
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Brevet Dao - Licensee		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not safeguard residents personal documents
Staff did not reorder residents medications timely resulting in resident missing medications

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 the facility and explained the reason for the visit.

The Department received the complaint on November 20, 2024 and the initial visit was conducted on November 25, 2024, during that visit the Department interviewed resident and staff. LPA Mendivil obtained copies of Resident 1’s (R1) documentation including: physician’s report, assessment, admission agreement, medication administration records and hospice documentation. Regarding the allegations Staff did not safeguard residents personal documents and Staff did not reorder resident’s medications timely resulting in resident missing medications, the investigation revealed the following:

It was alleged that staff did not safeguard resident’s personal documents. Per interview with Licensee Brevet Dao, Brevet stated all resident’s facility documents are stored in the locked medication cabinet in the hallway.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

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-20241120112843

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: 05/26/2026

NARRATIVE

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Licensee stated residents have access to their documents to review. Interviews with 1 out of 6 current residents, residents stated their items are safeguarded and have access to their documents/personal belongings. The remaining 5 residents were not oriented to time and space or did not wish to engage with LPA Mendivil.

It was alleged that staff did not reorder resident’s medications timely resulting in resident missing medications. Per interview with Licensee Brevet, Brevet stated that R1’s hospice nurse oversaw ordering medications and providing the medications to the facility. Brevet stated that they would contact hospice if a resident was going to run out of medication. No documentation or records of the dates the medications were missing were provided to LPA Mendivil. Brevet stated that staff started a pain medication management log for R1 and had R1 sign when medications were given. An interview with 1 out of 6 residents stated that they receive all of their medications and has not had an issue with the medications being ordered.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegations Staff did not safeguard resident’s personal documents, Staff did not reorder residents medications timely resulting in resident missing medication are determined to be UNSUBSTANTIATED meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC9099 (FAS) - (06/04)

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