306005837-11-17-2020-22-AS-MBAT-BVFTW2-20201117140450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005837
Report Date: 11/17/2020
Date Signed: 11/17/2020 02:07:57 PM

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:	ORCHARDS ASSISTED LIVING, THE		FACILITY NUMBER:	306005837
ADMINISTRATOR:	CONK, KELLY		FACILITY TYPE:	740
ADDRESS:	1 AMISTAD DRIVE		TELEPHONE:	(949) 443-8900
CITY:	RANCHO MISSION VIEJO	STATE: CA	ZIP CODE:	92694
CAPACITY:	90	CENSUS: 0	DATE:	11/17/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Executive Director (ED) Kelly Conk		TIME COMPLETED:	01:00 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	At 8:30 AM, Licensing Program Analyst (LPA), Mike Barrett contacted the facility via telephone for the purpose of conducting a pre-licensing inspection due to COVID 19 and pre-cautionary measures and met with Executive Director (ED) Kelly Conk, Chief Operating Officer (COO) Darolyn Jorgensen-Kares, Plant Operations Director (POD) Dan Meyers, Safety Director (SD) Tina Timonian, and Executive Director (ED) of Reata Glen, Suzanne Nasraty. LPA Barrett's observations during the physical plant inspection were as follows: Structure: Facility is a, newly constructed, two-story structure with 78 resident rooms including the memory care unit, which is located on the first floor and contains 20 rooms as well as delayed egress doors on the interior which were tested and observed to be in good operation. The facility has central air/heating system in the entire facility and each unit was equipped with individual thermostats for personal adjustment. LPA toured the interior and exterior of the facility with ED Conk and other lead staff, during which the inspection included units 107, 142, 151, 202, 225, 234 and 254 of the assisted living sections and units 132 and 138 in the memory care unit. Signal system: Signal system consist of alert buttons in the unit bathrooms located on the wall adjacent to the toilet situated approximately 12 inches off the floor for easy access in case of a fall. The residents will be given alert fobs that will be worn at all times that, when activated, will notify staff on PDA devices which notify the staff of resident and location. Both were tested and observed to be in good operation. Bedrooms for Residents: Bedrooms were unfurnished and equipped with kitchenettes, containing refrigerators/freezers and microwaves. Each unit was observed to have canned ceiling lights, smoke detectors and sprinklers in each room as well as a built in night light that remains on at all times. Continued on page 2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020

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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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: ORCHARDS ASSISTED LIVING, THE	FACILITY NUMBER: 306005837
	VISIT DATE: 11/17/2020

NARRATIVE

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Continued from page 1.
Bathrooms:
Each unit was equipped with private bathrooms that were equipped with grab bars by the toilets and in the shower stalls. The showers had a built-in foldable chair, lighting and non-skid mats. Toilets, shower head and faucets were observed to be clean and in good repair.
Hallways and stairwells:
The hallways were clean and observed to be free of obstructions. The facility had two (2) emergency stairwells that were clear of obstructions and equipped with the required emergency stairwell chairs at the top level of the stairwell. LPA observed and inspected eight (8) fire extinguishers in the hallways that were observed to be properly mounted and appropriately charged.
Amenities and Common Areas:
The facility had several common area including a grand living room that contained a fireplace that was properly screened and the furniture was situated to allow for proper social distancing. LPA observed several seating areas throughout the facility as well as recreations rooms, meeting rooms, library, media room and workout room. Within the center of the structure was the assisted living courtyard that was equipped with shaded seating, paved walkways and a putting green. The walkways were observed to be free of obstructions. On the exterior of the memory care unit was a courtyard designated to memory care patients that was completely fenced in and contained two (2) delayed egress gates that were tested and observed to be in good operation. In the courtyard were also shaded seating and paved walkways that were free of obstructions.
Kitchen and Food Service:
LPA toured the kitchen and inspected the walk in refrigerator, freezer, dishwashers and sanitation stations, temperature logs, food prep areas, fire extinguishers, wash basins, and dry goods storage. LPA observed that the facility had adequate supply of 7-day non-perishable and 2 day perishable food, the kitchen was clean and in good order, temperatures for the refrigerator and freezer were within regulation, temperature logs were completed and the fire extinguishers were properly mounted and appropriately charged.
Medication Rooms:
The facility had two (2) medications rooms on the premises, with the main medication room located on the second floor. Both rooms were secured by a locked door, contained locked cabinets, a locked refrigerator, first aid kits, PPE supplies and were observed to be clean and in good order.

Continued on Page 3.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3

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: ORCHARDS ASSISTED LIVING, THE	FACILITY NUMBER: 306005837
	VISIT DATE: 11/17/2020

NARRATIVE

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Continued from page 2.
Smoke Detectors:
Smoke detectors were located in each living unit and in throughout the common areas of the facility. The carbon monoxide detector was located in the grand living room beside the fireplace, was tested and observed to be in good working order.
Fire Clearance:
Fire clearance was granted for 90 non-ambulatory residents.
Water Temperature:
Water temperatures were measured in the units listed above and were as follows: 111.2, 114.1, 111.6, 110.7, 112.6, 114.1, 110.8 degreed Fahrenheit in the assisted living units and 107.4 and 113.5 degrees Fahrenheit in the memory care units.
Medications, First-Aid Kit & Book:
First aid kits were observed and inspected in the kitchen, front desk and two (2) Medication rooms and were observed to be complete.
Activities:
LPA observed the activities plan posted by the grand living room and discussed the activities plan with the Activities Director and observed the activities to be appropriate and in good variety.
Signs:
LPA observed that the facility had signs posted throughout the facility promoting social distancing, hand washing, symptoms reporting as well as Ombudsman contact information, Let-Us-No, Resident Personal Rights, Resident Council, Theft and Loss policy and emergency phone numbers.

LPA conducted Component III orientation. The following persons were present during the presentation:
Executive Director (ED) Kelly Conk, Chief Operating Officer (COO) Darolyn Jorgensen-Kares, Plant Operations Director (POD) Dan Meyers, Safety Director (SD) Tina Timonian, and Executive Director (ED) of Reata Glen, Suzanne Nasraty.

This facility's physical plant meets requirement of Title 22 regulations and LPA has recommended the facility for licensure.
The pre-licensing inspection has been completed. License will be granted upon approval by the Central Application Bureau (CAB). An exit interview was conducted and a copy of this report was provided to Executive Director (ED) Kelly Conk via email and an electronic read notification confirms the receipt.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020

LIC809 (FAS) - (06/04)

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