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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005837
Report Date: 06/13/2022
Date Signed: 06/13/2022 12:53:31 PM


Document Has Been Signed on 06/13/2022 12:53 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:ORCHARDS ASSISTED LIVING, THEFACILITY NUMBER:
306005837
ADMINISTRATOR:CONK, KELLYFACILITY TYPE:
740
ADDRESS:1 AMISTAD DRIVETELEPHONE:
(949) 443-8900
CITY:RANCHO MISSION VIEJOSTATE: CAZIP CODE:
92694
CAPACITY:90CENSUS: 45DATE:
06/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kelly Conk - Administrator
Amy Cole - Assisted Living Director		TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to The Orchards Assisted Living. LPA Velazquez was allowed entry into the facility and met with Administrator Kelly Conk and Assisted Living Director Amy Cole The purpose of today's Case Management visit was to follow-up on an Incident Report received in the Orange Regional Office on May 27, 2022 regarding Resident (R) #1.


On today's visit LPA Velazquez conducted interviews with staff. Per facility staff, R1 is currently out of the community spending time with family. LPA Velazquez was provided with copies of pertinent documentation from R1's file.





There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Administrator Kelly Conk and Assisted Living Director Amy Cole and a copy of this report along with the LIC 811 was provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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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