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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005837
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:53:56 AM


Document Has Been Signed on 10/31/2022 11:53 AM - 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: 50DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Amy Cole, Kelly ConkTIME COMPLETED:
12:10 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 10/31/2022 at 10:08am, Licensing Program Analyst (LPA) Jessica Cho arrived at The Orchards Assisted Living to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year with an emphasis on Infection Control. At 10:13am, LPA Cho was greeted and granted entry by Receptionist Nancy Chavez. LPA completed the Coronavirus 2019 (COVID-19) screening procedure and met with Administrator (Admin) Kelly Conk and Assisted Living Director (ALD) Amy Cole. There are no active COVID-19 cases as of today. Facility documents daily temperatures of visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs were posted on the main entrance and throughout the facility. The Complaint Posters (PUB475) did not meet the size requirement and were observed in the size of 11.5"x17.5." The facility is licensed for ninety non-ambulatory residents and has a hospice waiver for six. There are currently fifty residents living in the facility of which one is receiving hospice care.

At 10:34am, LPA Cho conducted a tour of the physical plant with Admin Kelly Conk and ALD Amy Cole. Also present were Safety Director Thad McKay and Plant Operations Manager Geoff Harvey. LPA observed all the common areas and randomly selected and inspected nine resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked with hand soaps. LPA observed hand washing signs in resident and public bathrooms. LPA Cho tested the hot water temperatures and the water temperatures measured between the ranges of 110.8 to 113.7 degrees Fahrenheit. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were mounted, fully charged, and serviced on 10/2022. Smoke/carbon monoxide detectors and auditory devices were tested by Dynalectric Service & Systems Group on 1/2022 and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
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 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: 10/31/2022
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
LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. Walkways around the facility were clear of hazards, and there were no security bars or weapons on the premises. LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit. An exit interview was conducted with Administrator Kelly Conk and Assisted Living Director Amy Cole, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3