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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700151
Report Date: 09/21/2023
Date Signed: 09/21/2023 11:01:18 AM


Document Has Been Signed on 09/21/2023 11:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ORANGE GROVE SENIOR LIVINGFACILITY NUMBER:
342700151
ADMINISTRATOR:TORRES,CHRISTINEFACILITY TYPE:
740
ADDRESS:228 GRACE AVENUETELEPHONE:
(916) 993-9099
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 6DATE:
09/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Christine TorresTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 09/20/2023 at 9:45 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee met with administrator, Christine Torres. The current Census is 6 with 2 facility staff.

LPA explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that was due 09/08/2023. During today's visit, LPA Lee reviewed staff and resident files previously cited on 08/24/2023 to see if POC have been corrected. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.



Based upon this inspection, LPA Lee observed the following:

1. Deficiency cited under Title 22 Regulation 87412(a) has not been cleared. The license did not complied with the terms of the POC by POC due date. A POC letter was not generated and provided to the licensee.

2. Deficiency cited under Title 22 Regulation 87506(a) has not been cleared. The license did not complied with the terms of the POC by POC due date. A POC letter was not generated and provided to the licensee.

The license did not complied with the terms of the POC by POC due date. As a result of this POCl visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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Document Has Been Signed on 09/21/2023 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ORANGE GROVE SENIOR LIVING
FACILITY NUMBER: 342700151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2023
Section Cited
CCR
87412(a)

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87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
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licensee agrees to up date facility staff files and notify LPA Lee by POC date 09/08/2023 by 5:00 PM by end of day. Administrator stated that staff has an physical appointment to get health screening completed on 10/05/2023 at 1:50 AM.
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee did not ensure 1 out of 6 facility staff files were current and up to dare, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Licensee agrees to email LPA Lee at pang.lee@dss.ca.gov a copy of staff LIC 503.
Type B
10/05/2023
Section Cited
CCR87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
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Licensee agrees to up complete and up date 5 out 6 resident files and notify LPA Lee by POC date 10/05/2023 by 5:00 PM by end of day. Administrator have given resident's conservator the documents to sign.
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Licensee agrees to up complete and up date 5 out 6 resident files and notify LPA Lee by POC date 09/08/2023 by 5:00 PM by end of day. LPA lee gave administrator a copy of what is missing in the 6 resident's file from LIC 858 on a word document.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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