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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005333
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:27:51 PM


Document Has Been Signed on 02/24/2023 12:27 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 HILL ELDERLY CAREFACILITY NUMBER:
306005333
ADMINISTRATOR:RODRIGUEZ, FRANCISFACILITY TYPE:
740
ADDRESS:2586 N ORANGE HILL RDTELEPHONE:
(714) 602-6072
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 6DATE:
02/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Glenn Navarro, Lead StaffTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho conducted a subsequent case management visit for the purpose to issue a citation after delivering the findings in connection to complaint control number: 22-AS-20230215102915. LPA spoke to Administrator by phone at 11:22am and explained the reason for the visit.

On February 21, 2023 during the initial complaint visit in connection to complaint control number: 22-AS-20230215102915, LPA observed Administrator (Admin) Jennifer Brower, Staff (1) and Staff (2) were not associated to the facility per review of the Personnel Roster via the Department’s Guardian Background Check dated February 17, 2023 and the Licensing Information System (LIS) dated February 22, 2023. Per Title 22 Regulation 87355 Criminal Record Clearance, facility is required to request a transfer criminal record clearance prior to working at the facility, therefore the preponderance of evidence standard has been met.

Based on observations, interviews conducted, and the records reviewed, a deficiency is being cited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See LIC809D. An immediate CIVIL PENALTY (LIC421BG) is assessed.

An exit interview was conducted with Lead Staff Glenn Navarro, and a copy of this report along with the LIC811, LIC809D, LIC421BG, and the appeal rights were provided during this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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Document Has Been Signed on 02/24/2023 12:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ORANGE HILL ELDERLY CARE
FACILITY NUMBER: 306005333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2023
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Licensee agrees to associate three of three staff and to provide proof to LPA via email by POC due date.
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This requirement is not met as evidenced by: Based on observations, interviews, and record reviews, three of three staff were not associated prior to working at the facility which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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