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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601290
Report Date: 02/02/2023
Date Signed: 02/02/2023 02:37:10 PM


Document Has Been Signed on 02/02/2023 02:37 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:LA ORINDA CARE HOMEFACILITY NUMBER:
075601290
ADMINISTRATOR:WONG, RONALD G.FACILITY TYPE:
740
ADDRESS:2180 LA ORINDA PLACETELEPHONE:
(925) 798-3570
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 4DATE:
02/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Ronald Wong, Administrator/LicenseeTIME COMPLETED:
02:50 PM
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On 02/02/2023 at 01:05 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Ronald Wong, Administrator/Licensee.

The facility submitted an LIS 624 about R1's death, LPA came to collect additional information surrounding this incident. LPA interviewed 2 staff. LPA collected the following documents from R1s file; Physicians report, Pre appraisal/ needs a and services, Preplacement appraisal, Medication log and Physicians Orders for Life-Sustaining Treatment (POLST).

LPA will need more time to evaluate the documentation, LPA will follow up if needed. Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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