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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200274
Report Date: 03/25/2024
Date Signed: 03/25/2024 12:31:08 PM

Document Has Been Signed on 03/25/2024 12:31 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: 6DATE:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:FLORENCIA RICASA, CAREGIVERTIME COMPLETED:
12:50 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 3/25/2024 at 9:50am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual 1-year required inspection. LPA met with Florencia Ricasa, Caregiver, and explained the purpose of the visit. The administrator arrived at approximately 11:00am and currently holds a certificate (#6010407735) that expired on 11/14/2023 waiting for renewed certificate. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden clients. No clients present during inspection.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) total bedrooms and two (2 ) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 3/16/2022. Fire drill last conducted 2/6/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ORCHID HOME
FACILITY NUMBER: 079200274
VISIT DATE: 03/25/2024
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
26
27
28
29
30
31
32
Continued from LIC809.

Four (4) staff records and four (4) clients' records were reviewed and all are complete.

LPA observed the following deficiencies:

· At 10:50am, LPA observed an unlocked closet with chemicals such as Ajax, Clorox bleach spray, Lysol, Fabreeze.

The following forms to be updated and submitted to CCLD by 04/04/2024:

· LIC610D Emergency disaster plan (9 pages)
· LIC500 (Personnel Record)
· Client Roster
· LIC308 (Designation of facility Responsibility)

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/25/2024 12:31 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/25/2024 at 12:05 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ORCHID HOME
FACILITY NUMBER: 079200274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having an unlocked closet with chemicals such as Ajax, Clorox Bleach Spray, Lysol, Fabreeze which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
1
2
3
4
Administrator agreed to conduct in-service training with staff and provide CCLD with a copy of the topics and signature of attendees by the POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4