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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 06/26/2026
Date Signed: 06/26/2026 12:24:32 PM

Document Has Been Signed on 06/26/2026 12:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IRIS GUEST HOMEFACILITY NUMBER:
306005722
ADMINISTRATOR/
DIRECTOR:		DAO, BREVETFACILITY TYPE:
740
ADDRESS:2702 N BERKELY STTELEPHONE:
(714) 310-4436
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 4DATE:
06/26/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jean VeracrizTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sam Haddadin conducted a Case Management visit to the facility for the purpose of conducting a health and safety check. Upon arrival, LPA was greeted by Administrator (AD) Jean Veracruz, who granted entry into the facility.

During the visit, LPA observed four residents in care. LPA toured the residents’ bedrooms and observed that the bedrooms contained the required furnishings and accommodations. However, Bedroom 1 had a broken closet door located directly behind the resident’s head area, which posed an immediate health and safety risk to the resident in care.

LPA also observed that Bathroom 1 had a nonworking sink and no running hot water, which posed an immediate health and safety risk to residents in care. LPA checked the hot water temperature in Bathroom 2, which measured 116.9 degrees Fahrenheit.

During the inspection of the kitchen, LPA observed knives and sharps unsecured under the kitchen sink, along with cleaning supplies, which posed an immediate health and safety risk to residents in care.

Deficiencies are being cited during today’s visit per Title 22 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, along with appeal rights, was provided.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/26/2026 12:24 PM - It Cannot Be Edited


Created By: Samer Haddadin On 06/26/2026 at 11:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2026
Section Cited
CCR
87303(a)

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87303(a), Maintenance and Operation, states: “The facility shall be clean, safe, sanitary and in good repair at all times.” This requirement was not met as evidenced by:
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Plan of Correction: The Licensee/Administrator shall repair or remove the broken closet door to ensure the resident’s bedroom is maintained in safe and good repair.
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 Based on observation, LPA observed Bedroom 1 had a broken closet door located directly behind the resident’s head area. This posed an immediate health and safety risk to the resident in care.
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 Proof of correction, including photos and/or repair invoice, shall be submitted to LPA by the POC due date.
Type A
06/29/2026
Section Cited
HSC87303(e)(6)

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87303(e)(6), Maintenance and Operation, states: “Toilet, handwashing and bathing facilities shall be maintained in operating condition.” This requirement was not met as evidenced by: Based on observation,
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The Licensee/Administrator shall ensure Bathroom 1 sink is repaired and maintained in operating condition, and that hot water is available to residents. The Licensee/Administrator shall
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LPA observed Bathroom 1 had a nonworking sink and no running hot water. This posed an immediate health and safety risk to residents in care.
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 submit proof of correction, including photos, repair invoice, and a hot water temperature log, to LPA by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/26/2026 12:24 PM - It Cannot Be Edited


Created By: Samer Haddadin On 06/26/2026 at 11:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRIS GUEST HOME
FACILITY NUMBER: 306005722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2026
Section Cited
HSC
87309(a)

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87309(a), Storage Space and Access,"the licensee shall ensure that disinfectants, cleaning solutions knives,tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage"
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The Licensee/Administrator shall immediately remove and secure all knives, sharps, cleaning supplies, disinfectants, and other hazardous items in locked storage. The Licensee/Administrator shall conduct staff training regarding
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This requirement was not met as evidenced by: Based on observation, LPA observed knives and sharps unsecured under the kitchen sink, along with cleaning supplies. The items were accessible to residents in care and posed an immediate health and safety risk.
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proper storage of hazardous items and submit proof of correction, including photos and staff training documentation, to LPA by the POC due date.

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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2026


LIC809 (FAS) - (06/04)
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