342701385-4-29-2025-27-AS-KVIA-DG6QU3-20250428122805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701385
Report Date: 04/28/2025
Date Signed: 04/29/2025 10:08:00 PM

Document Has Been Signed on 04/29/2025 10:08 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ORANGE ORCHARD HOME		FACILITY NUMBER:	342701385
ADMINISTRATOR/ DIRECTOR:	NAVARRO, FLORDELIZA		FACILITY TYPE:	735
ADDRESS:	12268 HABITAT WAY		TELEPHONE:	9166935088
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95742
CAPACITY: 4		CENSUS: 3	DATE:	04/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Flordeliza Navarro		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 04/28/25. LPA identified herself upon arrival, stated the purpose of the visit, and met with the Licensee/Administrator, Flordeliza Navarro. A brief interview followed. LPA presented Licensee/Administrator with a list of documents to be collected during this visit: LIC 500, LIC 9020, LIC 308, LIC 405, LIC 610E, a copy of liability insurance, updated facility sketch, and a copy of the Designated Facility Administrator's Certificate (# 7016947735, expires 08/19/26). The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. LPA pulled a sample of 9 items from the refrigerator, all but 2 had the appropriate packaging and dates on them as required. The 2 that did not were leftovers from staff. LPA provided technical assistance and highlighted that all opened packages needed to be dated and labeled and that if they belonged to staff, they need to be labeled as such. LPA compared the facility sketch to the current floor plan and they were identical with no changes. LPA inspected the 4 resident bedrooms. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. LPA noted soap, paper towels, and trash cans in the bathrooms. The hot water temperature was measured at 113.2 degrees Fahrenheit and was in compliance. The fire extinguisher was last serviced on 02/05/25 by Jorgenson Fire and was also in compliance.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ORANGE ORCHARD HOME	FACILITY NUMBER: 342701385
	VISIT DATE: 04/28/2025

NARRATIVE

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was completely fenced in. LPA observed that all screens and gutters were in good repair.

The LPA observed that there was a cabinet with a lock in the kitchen for medication storage. Resident medications were primarily the pill packs provided by the pharmacy and were stored in a locked cabinet to the left of the fireplace. LPA reviewed storage, dosing, and destruction procedures with the Licensee/Administrator and 2 of their staff. A review of the First Aid kit by the LPA found it to be complete and in compliance.

A file review was completed by the LPA. LPA reviewed 2 staff and 2 resident files. Files reviewed were in compliance at the time of inspection.

LPAs compared the LIC 500 (Staff Roster) with the Guardian roster to ensure that all staff had the appropriate background clearances to care for the residents. All were in compliance at the time of this inspection.

This facility was required to notify Community Care Licensing when they admitted their first client. It did not. This deficiency was cited on the LIC 809D page.

According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's inspection. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/29/2025 10:08 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 04/28/2025 at 12:10 PM

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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ORANGE ORCHARD HOME	FACILITY NUMBER: 342701385
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80063(a)

80063 Accountability (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and a review of records, the licensee did not notify Community Care Licensing (CCL) when they admitted their first client so a post licensing visit could be scheduled. They admitted 3 clients without alerting CCL which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Licensee stated that they will email Community Care Licensing (CCL) an attestation that they understand that CCL needs to be updated according to regulations requirements. This task will be completed by the close of business on 05/02/25. Email to use: CCLASCPSacramentoRO@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC809 (FAS) - (06/04)

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