Blue Jasmine Villa

Type of visit: Required - 1 Year

On December 9, 2025, Licensing Program Analyst (LPA) Garlli Tat conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA explained the purpose for the visit and was greeted and granted entry by Administrator KC. For this visit, there is one staff member on duty, who is background cleared and associated. AD assisted with the inspection. The PUB475 ‘See Something, Say Something’ poster was observed to be located by the front entrance. LPA observed the Administrator's Certificate for Administrator 1 has been renewed on February 6, 2025. The facility is a Residential Care facility for the Elderly (RCFE) licensed for six residents, six of which may be non-ambulatory, six of which may be bedridden, and a hospice waiver for six. LPA toured the interior and exterior portions of the facility with AD. For this visit, there are a total of two non-ambulatory residents in care, none are bedridden, and none are on hospice. The facility is a single story home. There are a total of four bedrooms, one of which is a private resident bedroom, two shared bedrooms, and one bedroom for staff. LPA toured each bedroom with the AD and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and free of any hazards. LPA observed the staff room is kept locked and inaccessible to residents in care. Smoke and carbon monoxide detectors as well as auditory exit alarms were tested and operational. There are a total of two full bathrooms. Continued on LIC 809-C. Bathrooms were observed to be in good repair, toilets and faucets were operational and showers were equipped with grab bars and non-skid floor mats. Water temperature in the bathrooms were measured to be between 113.0 and 116.7 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked underneath the sink and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the garage. Fire extinguisher had a purchase date of May 15, 2025. There is a fire sprinkler system in the kitchen. LPA observed the emergency disaster and evacuation plan, which is posted by the front entrance. LPA observed the facility conducted their last emergency disaster drill on September 18, 2025. Facility had back-up emergency food and water supplies, located in the garage. LPA observed that the First Aid kit had all the required components. Medications were observed to be locked in a medication cabinet in the garage, inaccessible to residents in care. Chemicals were observed to be locked in the garage. LPA observed the door leading to the attached two car garage is kept locked and inaccessible to residents in care. The garage is used for storage and laundry. For the exterior portion, LPA observed patio furniture under shading, and the grounds were free of any hazards or obstructions. There are two exit gates in the backyard that can be opened in case of an emergency. No bodies of water were observed. During this visit, two resident files and three staff files were reviewed. All staff are background cleared and associated with the facility. LPA reviewed residents’ medication and medication records and one resident interview was conducted. Based on today's observations, there are no deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator. This report was reviewed with the Administrator and a copy was provided at the end of the visit.the state’s words, verbatim · CDSS document, Dec 9, 2025

Allegation investigated: Resident in care sustained unexplained injuries Staff handled resident in a rough manner Staff spoke inappropriately to resident in care Staff did not follow proper reporting requirements

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and clients. Regarding the allegations that resident in care sustained unexplained injuries, staff handled resident in a rough manner, staff spoke inappropriately to resident in care and staff did not follow proper reporting requirements, the investigation revealed the following: Per interviews conducted with facility staff, Resident 1 (R1) did not receive a head injury while at the facility. Resident had returned from the day program when responsible party called 911 to assess bruising on the resident's head. Facility Administrator states paramedics deemed the resident cleared but responsible party requested transfer to Hoag Hospital Irvine. Hospital discharge notes reviewed indicate: "6/14/2023 11:51 PM PDT The patient's condition did not warrant admission to the hospital. Patient is clinically stable, the emergency department evaluation does not indicate that they are in danger of imminent deterioration, and deemed safe for outpatient management." CONT ON LIC 9099C DATED 11/19/2025 Unsubstantiated No mention is made of a concussion diagnosis at that time. Incident report dated 06/14/2023 indicated resident returned from day program with a bruised eye lid. Incident report stated responsible party was notified about the bruising after day care. Facility staff denies knowledge of a bruised hand. LPA observed video surveillance from 06/12/2023 showing staff holding onto R1's arm as family member takes the resident out. LPA did not observe any abuse or aggression on video and two out of two staff and two out of two residents deny any verbal or physical aggression from staff. Based on observation, record review and interviews, LPA is unable to corroborate the allegations. Therefore the allegations are deemed Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 22-AS-20230725154002

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Zayra Sanchez and Administrator (AD) Kaveh Chavoshpour. For today’s visit, LPA observed a total of two residents in care and one staff member on duty. During today's visit LPA observed the AD certificate for AD Kaveh Chavoshpour which expires on March, 06, 2025. LPA toured the interior and exterior portions of the facility with AD. The facility is a one story structure and is licensed for six non-ambulatory residents, of which six may be on hospice and six bedridden. There are a total of four bedrooms, of which six are resident bedrooms and one staff bedroom. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 106.8 and 109.5 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged and located in the garage. During today's visit LPA observed the residents eating breakfast and working on a puzzle with staff. CONTINUED ON LIC809C... LPA observed the emergency disaster and evacuation plan which is located by the main entryway. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. For the exterior portion, LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard. No bodies of water were observed. LPA reviewed two resident files and three staff files. LPA interviewed residents and staff present. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. LPA advised AD to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. An exit interview was conducted with AD Chavoshpour. A copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Dec 17, 2024

Allegation investigated: Staff installed a blue light in the resident's room that is interfering with the resident's sleep. Staff did not seek consent from resident's POA or medical team to install a blue light in the resident's room.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Kaveh Chavoshpour. It was alleged that staff installed a blue light in the resident's room that is interfering with the resident's sleep. Per documentation review, LPA observed that resident 1 (R1) did have a blue light installed in the room, however upon LPA conducting an interview with R1, R1 stated "I like it" and when asked about sleep interference, R1 stated "I sleep very good" and denied of any interference with sleep. It was alleged that staff did not seek consent from resident's POA or medical team to install a blue light in the resident's room. Per documentation review and observation, it was observed that R1 had a blue light in the room but the color of the light was randomly chosen due to R1 having a light in the room that had multiple colors. Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Chavoshpour. A copy of this report was provided and explained. R1's POA then expressed concerns regarding the light, therefore, R1's nurse suggested for the facility to not utilize a blue light to which then the facility changed the light to a different color instead, and did not continue to use the blue light. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with AD Chavoshpour. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 22-AS-20230804130842

Allegation investigated: Resident is being denied medical services

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty (S1) Soheila Amirmakky. Facility administrator (AD) Zahrabigom "Zahra" Fakim was unable to be present during time of visit, however provided consent for S1 to receive and sign report. It was alleged that resident is being denied medical services. LPA De Perio conducted a total of 4 interviews that consisted of staff and residents, of which the 4 interviews did not corroborate with the allegation by stating that the facility does assist residents with medical services and does not deny a resident from obtaining medical services. Per record review, on 8/16/23, resident 1 (R1) was given an order for wheelchair due to R1 being a fall risk, however the order did not specify when to use the wheelchair. LPA De Perio interviewed R1 who verified that staff offer R1 to use the wheelchair, but R1 denies in wanting to use it. R1 stated "I don't need it, so why would I use it. I walk just fine". Unsubstantiated During the tour of the facility, LPA De Perio observed that the wheelchair was located in R1's room and also observed that that R1 was ambulating independently around the facility. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with S1 Amirmakky and AD Fakim via phone call. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 22-AS-20230815123016

Allegation investigated: Staff did not assist resident with prescribed medications.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty (S1) Soheila Amirmakky. Facility administrator (AD) Zahrabigom "Zahra" Fakim was unable to be present during time of visit, however provided consent for S1 to receive and sign report. It was alleged that staff did not assist resident with prescribed medications. LPA De Perio conducted a total of 4 interviews that consisted of staff and residents, of which the 4 interviews did not corroborate with the allegation by stating that the facility staff does assist residents with prescribed medications. 2 of the interviews conducted with residents stated that staff help "all the time". Per record review, LPA observed that facility documents when medications are given to a resident, along with updating the residents medication chart when the residents doctor prescribes new medication. Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with S1 Amirmakky and AD Fakim via phone call. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 22-AS-20230816091158