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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005722
Report Date: 08/04/2026
Date Signed: 08/06/2026 09:57:41 AM

Document Has Been Signed on 08/06/2026 09:57 AM - 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:
08/04/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:30 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 health and safety check, LPA observed a cabinet containing chemicals, sharps, and cleaning supplies that was unlocked and accessible to residents in care. AD acknowledged the cabinet was not secured. This observation does not comply with California Code of Regulations, Title 22, Section 87309(a), Storage Space, which requires disinfectants, cleaning solutions, poisons, and other items that could pose a danger if readily available to residents to be stored where they are inaccessible.

LPA also inspected the facility’s food supply and observed that the facility did not maintain a minimum two-day supply of perishable food for the residents in care. AD acknowledged that the available perishable food supply was insufficient. This observation does not comply with California Code of Regulations, Title 22, Section 87555(b)(26), General Food Service Requirements, which requires facilities to maintain a minimum one-week supply of nonperishable food and a minimum two-day supply of perishable food on the premises.
Both resident bathrooms were observed to be clean and operational. Hot water temperatures were measured between 111.5 and 113.1 degrees Fahrenheit.

Deficiencies are being cited during today’s visit pursuant to 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.

Alisa Ortiz
Samer Haddadin
DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2026
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 08/06/2026 09:57 AM - It Cannot Be Edited


Created By: Samer Haddadin On 08/04/2026 at 05:25 PM
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: 08/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2026
Section Cited
CCR
87309(a)

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87309(a)Disinfectants, cleaning solutions, poisons, firearms, and other items that could pose a danger if readily available to residents shall be stored where inaccessible to residents.
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The Administrator secured the cabinet containing the chemicals, sharps, and cleaning supplies during the visit.
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This requirement was not met as evidenced by: Based on observation, the Licensee failed to ensure that chemicals, sharps, and cleaning supplies were inaccessible to residents. During the visit, LPA observed an unlocked cabinet containing chemicals, sharps, and cleaning supplies. The cabinet was accessible to residents in care. This poses an immediate health and safety risk to residents.
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The Licensee agreed to conduct staff training regarding the proper storage of hazardous items and submit proof of training to the Licensing office by the POC due date.
Type A
08/07/2026
Section Cited
CCR87555(b)(26)

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87555(b)(26) General Food Service Requirements Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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The Licensee agreed to purchase sufficient perishable food to maintain a minimum two-day supply and submit photographs and purchase receipts to the LPA by the POC due date.
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This requirement was not met as evidenced by: Based on observation the Licensee failed to maintain a minimum two-day supply of perishable food on the premises. During the visit, LPA inspected the facility’s food supply and observed that there was not enough perishable food to meet the needs of the residents in care for a minimum of two days. The Administrator acknowledged that the facility’s perishable food supply was insufficient. This poses a potential health, safety, and personal-rights risk to residents 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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