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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700619
Report Date: 07/11/2023
Date Signed: 07/11/2023 01:40:00 PM


Document Has Been Signed on 07/11/2023 01:40 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:YELLOW ORCHID LLCFACILITY NUMBER:
342700619
ADMINISTRATOR:BHADE, KIRENDEEPFACILITY TYPE:
740
ADDRESS:9470 SEA CLIFF WAYTELEPHONE:
(916) 432-0685
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kirendeep BhadeTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Kirendeep Bhade and explained the purpose of the visit.

LPA Moleski reviewed two resident files (R1-R2) and two staff files (S1-S2).

S3 was not associated to the facility roster. LPA Moleski reviewed the Licensing Information System and saw that S3 had been removed from the roster on 7/3/23. Regional Office staff were contacted, and they informed LPA Moleski that an incomplete fingerprint reminder was sent out on 6/27/23.

R3's LIC 602 indicated that R3 is bedridden. The facility's fire clearance is for 6 ambulatory or non-ambulatory only.

LPA Moleski toured the facility with Bhade and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents.

LPA Moleski observed fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S1).

This facility is being cited per HSC section 1569.17(c)(1)(A) and 22 CCR section 87202(a)(2). An immediate civil penalty of $500 for each violation was assessed. An exit interview was held. Appeal rights and a copy of this report were left with Bhade.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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 2


Document Has Been Signed on 07/11/2023 01:40 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: YELLOW ORCHID LLC
FACILITY NUMBER: 342700619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of R3's records, the licensee accepted and/or retained a bedridden resident without the appropriate fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Licensee agrees to submit a request for a new fire clearance and will send information regarding the request and the appropriate forms to LPA Moleski.
vincent.moleski@dss.ca.gov
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of LIS, Guardian, and the facility roster, the licensee did not ensure S3 received a fingerprint clearance and/or facility association which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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S3 submitted a live scan request form during this visit. This POC will be cleared.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2