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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700971
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:01:39 PM

Document Has Been Signed on 04/04/2023 12:01 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
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:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ming Him (Ryan) Chan TIME COMPLETED:
12:15 PM
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On 4/4/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility announced to conduct a scheduled and required 1 year annual visit. The facility has no clients at this time. LPA Jensen met with Licensee Ryan Chan and explained the purpose of today's visit. Ryan holds current Administrator's certificate # 6047821735 good through 5/3/24.

The facility is licensed for 4 residents, 1 of which may be non-ambulatory. LPA Jensen toured the grounds and interior of the facility. All exterior paths were free of debris. The backyard was observed to have an area that is shaded and had sufficient outdoor patio furniture for resident use. The facility has an ADA accessible ramp at the entrance and a stand with hand sanitizer posted outside of the entrance. The facility has all required postings including but not limited to the latest Provider Information Notices, "See Something, Say Something" Disability Rights, employee rights, Emergency Disaster Plans, infection control mitigation and activities calendar. The Emergency Disaster Plan was reviewed and determined to be in compliance.

The facility was observed to be sanitary and free of odor. LPA Jensen observed sufficient furniture and lighting throughout. The facility maintains an adequate supply of linen and PPE. Sharp objects and toxins were observed to be locked and inaccessible to future residents in care. There is a locked medication cabinet available for use. The facility maintains an first aid kit that was observed to be complete with scissors, tweezers, thermometer, various wound dressings and manual. The carbon monoxide detector was tested and found to be ion good working order. The fire extinguisher was purchased on 4/12/22 and is in compliance. The thermostat was set at 68 degrees and is in compliance. The water temperature in the resident bathrooms was measured an 110.8 and falls within the required regulatory range of 105-120 degrees.

Continued on LIC 809C....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ORCHID CARE
FACILITY NUMBER: 392700971
VISIT DATE: 04/04/2023
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Licensing fees were determined to be current with the last payment made 3/24/23.

LPA Jensen requested the following documentation to be emailed to maja.jensen@dss.ca.gov by 4/11/23:

LIC 500
Liability insurance
Surety Bond
Infection Control Plan

The facility was determined to be in substantial compliance. An exit interview was conducted and a copy of this report was given to Ryan Chan.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC809 (FAS) - (06/04)
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