306003406-12-1-2022-22-AS-CDPO-CLPV2S-20221201150338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003406
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:03:59 PM

Document Has Been Signed on 12/01/2022 03:03 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ORANGE MANOR, THE		FACILITY NUMBER:	306003406
ADMINISTRATOR:	AIDA MARTIRES		FACILITY TYPE:	740
ADDRESS:	1824 NORTH SHAFFER ST.		TELEPHONE:	(714) 283-2474
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY: 6		CENSUS: 5	DATE:	12/01/2022
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Facility Administrator-Aida Martires		TIME COMPLETED:	03:17 PM

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/22/2022. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who contacted facility administrator (AD) Aida Martires.

For today's visit, LPA De Perio verified that there are 5 residents in care of which 3 are on hospice and one staff on duty.

On 11/22/22, facility did not ensure that 3 out of the 4 staff files reviewed, had the required 20-hours of annual training, which poses an immediate health and safety or personal rights risk to persons in care.

*Deficiency cited under Title 22 Regulation 1569.625(b)(2) pertaining to Staff Training has been CLEARED. Licensee has submitted proof of the completed required staff training to CCL and assigned LPA on 11/23/22. Licensee has complied with the terms of the POC.

On 11/22/22, facility did not ensure that clearance for one of the staff present at the facility was received, which poses an immediate health, safety or personal rights risk to persons in care.

*Deficiency cited under Title 22 Regulation 87355 pertaining to Criminal Record Clearance has been CLEARED. Licensee has submitted proof of the completed clearance and background check to CCL and assigned LPA on 11/23/22. Licensee has complied with the terms of the POC.

For this visit, no citations were issued and no deficiencies were issued.

LPA De Perio conducted an exit interview with AD Martires and a copy of this report and cleared POC letter was provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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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