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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603092
Report Date: 01/24/2021
Date Signed: 01/24/2021 11:43:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:WHITE ORCHID GUEST HOMEFACILITY NUMBER:
374603092
ADMINISTRATOR:ESTEPA, STANFACILITY TYPE:
740
ADDRESS:978 WEST 2ND AVETELEPHONE:
(760) 737-6030
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:5CENSUS: 3DATE:
01/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Stan EstepaTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Eva Torres conducted a virtual visit via Zoom to cite for violations that were discovered during an open investigation. LPA identified herself, spoke with Administrator, Stan Estepa, and disclosed the purpose of the phone call. The investigation included a review records and interviews conducted.

During an investigation that was initiated on 03/10/20, evidence confirmed that hot water was not always readily available to the residents in care. Also, a review of the resident’s records revealed that the facility did not thoroughly develop an appropriate service plan to meet the resident's needs, as the care plans were found to be incomplete with blank pages.

Deficiencies are being cited per Title 22, Div. 6, Chap 8. A virtual exit interview was conducted with Administrator, Stan Estepa, and Licensee/Appeal Rights (LIC 9058 01/16) along with a copy of this report was provided to the administrator via email. A return email from the administrator will confirm receipt of documents.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WHITE ORCHID GUEST HOME
FACILITY NUMBER: 374603092
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2021
Section Cited

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Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving, and grooming shall deliver hot water between the temperature of 105 and 120 degrees. This requirement was not met by:
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Based on interviews conducted and records reviewed, the facility did not ensure hot water was readily available to meet the resident’s hygiene needs. This act posed a potential health risk to the resident in care.
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Type B
02/05/2021
Section Cited

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Reappraisals: The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met by:
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Based on interviews conducted and records reviewed, the facility did not thoroughly develop an appropriate service plan to meet resident’s needs. This act posed a potential health risk to the residents in care.
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The administrator informed the LPA that they will forward their plan by the POC due date of 02/05/21.
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: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica TorresTELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2021
LIC809 (FAS) - (06/04)
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