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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700971
Report Date: 04/04/2022
Date Signed: 04/04/2022 11:18:53 AM

Document Has Been Signed on 04/04/2022 11:18 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ORCHID CAREFACILITY NUMBER:
392700971
ADMINISTRATOR:CHAN, MING HIMFACILITY TYPE:
735
ADDRESS:421 E BANBURY DRTELEPHONE:
(415) 321-0868
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 0DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Ming Him ChanTIME COMPLETED:
11:15 AM
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On 4/4/22 at 9:40am Licensing Program Analyst (LPA) Maja Jensen arrived announced to conduct a required one year annual visit. LPA Jensen met with Licensee Ming Him Chan and explained the purpose of today's visit. LPA Jensen was screened for COVID at the entrance of the facility and allowed access the premises. Licensee Ming Him Chan holds current Administrator's certificate # 6047821735. There are currently no clients residing at the facility.

The facility is a single story structure with wheelchair accessibility. LPA Jensen observed all required signage, including COVID related, to be prominently posted. LPA toured the facility indoors and outdoors including but not limited to dining room, living room, kitchen, garage, 2 bathrooms, 4 bedrooms and backyard. The facility is licensed for 4 clients of which 1 can be non-ambulatory. One bathroom is for clients and has sufficient space to accommodate a non-ambulatory client and one bathroom is for staff.

The facility was observed to be adequately furnished and sanitary. The facility temperature was set at 70 degrees which is within the required range of 68-85 degrees. The water temperature in the bathroom was measured at 106.6 which is within the required range of 105-120 degrees. The fire alarm and carbon monoxide detectors were tested and observed to be in good repair. The fire extinguisher was purchased on 4/17/21 and is in compliance.

The kitchen was observed to have locked storage for sharp objects and toxins. Two first aid kits were observed to be complete. Lighting was observed to be adequate throughout the facility. Night lights were observed to be available throughout the hallways and emergency lighting was available. LPA Jensen observed a 30 day supply of PPE as well as emergency food and water supplies. An activity calendar and meal menu was observed to be posted.

No deficiencies were cited as a result of today's visit. An exit interview was conducted and left with the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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