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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005862
Report Date: 03/04/2025
Date Signed: 03/24/2025 11:39:38 AM

Document Has Been Signed on 03/24/2025 11:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LORANE WAY HOMEFACILITY NUMBER:
306005862
ADMINISTRATOR/
DIRECTOR:		SOONTHORNPONG, SUPARBFACILITY TYPE:
735
ADDRESS:1587 W LORANE WAYTELEPHONE:
(714) 591-5185
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 4CENSUS: 4DATE:
03/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:Suparb SoonthornpongTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection due to a special incident report (SIR) received on February 17,2025. Upon arrival, LPA Vanegas was greeted and granted entry to the facility by Direct Support Staff (DSP) Fe Pulmano. LPA Vanegas met with Licensee (LC) Suparb Soonthompong and explained the purpose for the inspection.

During the course of the investigation LPA Vanegas conducted a tour of the facility, conducted health and safety checks of clients, reviewed resident roster, staff roster, staff files, and resident files. Interviews were conducted with facility staff (S1), LC, Program Manager (PM) of adult day program, and alleged victim. The interviews revealed the following information: Interview with Staff 1 (S1) Client 1 (C1) woke up for their day program on February 11, 2025. C1 left in good health and not complaining of any pain, according to S1 when C1 arrived from adult day program later that day C1 began to gesture to their right shoulder expressing pain. S1 conducted a body check and observed C1’s right shoulder to be swollen, S1 provided C1 with an ice pack, and advised C1 to rest their arm.

Interview with LC corroborated the same time frame and same event’s that took place. According to S1 the next day on February 12, 2025, C1’s right shoulder was still swollen and had sever bruising. S1 was concerned about this injury happening at the adult day program. Per S1 client’s right shoulder got more swollen over the next few days and C1 had a doctor’s appointment scheduled for February 17, 2025. Per S1 on February 17, 2025, C1 sustained a fall at the facility. Per S1 C1 was taken to their doctor’s appointment, and then taken to the emergency room where C1 was diagnosed with a closed fracture to their clavicle.

Interview with PM revealed the following: On February 12, 2025, PM was notified about the incident that occurred, PM advised that part of their daily procedures is to conduct visible body checks before taking clients to the program, and after dropping the clients off at the facility. PM stated that both body checks they conducted did not reveal any visible marks or swelling.

CONTINUED ON LIC809C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LORANE WAY HOME
FACILITY NUMBER: 306005862
VISIT DATE: 03/04/2025
NARRATIVE
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Interview with C1 revealed the following: C1 is nonverbal; however, they were able to gesture that they fell at the facility, and hit their head, and eye. However, they were unable to confirm the date it occurred.

Based on interviews conducted during today’s inspection citations will be citied per tittle 22-chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with Licensee Suparb Soonthompong, and a copy of this report was left at the facility.




SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 04:12 PM - It Cannot Be Edited


Created By: William Vanegas On 03/04/2025 at 11:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LORANE WAY HOME
FACILITY NUMBER: 306005862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2025
Section Cited
CCR
87211(a)(1)(B)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted for any injury observed ....
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Licensee will submit incident report by P.O.C due date, and send proof of correction to LPA via email.

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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:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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