<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200274
Report Date: 12/09/2022
Date Signed: 12/09/2022 04:29:33 PM

Document Has Been Signed on 12/09/2022 04:29 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:ORCHID HOMEFACILITY NUMBER:
079200274
ADMINISTRATOR:MIRANDA, RAQUEL B.FACILITY TYPE:
735
ADDRESS:109 ORCHID CTTELEPHONE:
(650) 438-4468
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 5DATE:
12/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Lisa Ignacio, CaregiverTIME COMPLETED:
04:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/09/2022 at 2:35PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a case management visit regarding an incident report received on 12/01/2022. LPA met with Caregiver Lisa Ignacio and Administrator Raquel Miranda.

Incident report dated 11/30/2022 revealed that Staff 1 (S1) was accused of pushing Resident 1 (R1). Facility notified R1's responsible party, CCLD and Staff 1 (S1) that day program will be submitting a incident report stating S1 pushed R1 while assisting R1 to the van.

LPA interviewed three (3) of four (4) staff. LPA was not able to interview Resident 1 (R1) due to diagnosis. Interview with Staff 1 (S1) revealed that S1 was assisting R1 to the van for transportation to day program and R1 miss stepped and hurt her leg. Staff 3 (S3) conducted an investigation, it was found to be unsubstantiated.

LPA requested the following documents to be emailed: Staff roster, Resident roster, and training documents for S1.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1