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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700151
Report Date: 11/02/2023
Date Signed: 11/02/2023 09:07:22 AM


Document Has Been Signed on 11/02/2023 09:07 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: DATE:
11/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:11 AM
MET WITH:Teresa Autencio TIME COMPLETED:
09:15 AM
NARRATIVE
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Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 11/02/2023 at 8:05 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee met with direct care staff, Teresa Autencio and explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of corrections that was due on 10/23//2023. During today's visit, LPA Lee reviewed residents and staff files to ensure all deficiencies previously cited have been corrected.

Based upon this inspection, the LPAs observed the following:
I. Deficiency cited under Title 22 Regulation 87412(a) has been cleared. The Licensee complied with the terms of the POC by POC due date 10/23/2023. A POC letter was generated and provided to the licensee.

2. Deficiency cited under Title 22 Regulation 87506(a) has been cleared. The licensee complied with the terms of the POC by POC due date 10/23/2023. A POC letter was generated and provided to the licensee.

An exit interview was held, and a copy of this report, LIC 809, was given to the facility at the end of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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