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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005837
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:00:58 PM


Document Has Been Signed on 05/30/2023 03:00 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: 57DATE:
05/30/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Kelly ConkTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced collateral visit in conjunction with complaint investigation 22-AS-20230410142343 at another licensed facility. LPA was greeted and granted entry into the facility by Administrator Kelly Conk and explained the reason for the visit.

During the visit, LPA met with Resident 1 (R1) to gather information pertaining to complaint #22-AS-20230410142343. Resident agreed to speak with LPA and the interview was conducted in the resident's room.











Exit interview conducted and a copy of this report was emailed to Administrator.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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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