<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700971
Report Date: 07/08/2024
Date Signed: 07/09/2024 12:08:31 PM

Document Has Been Signed on 07/09/2024 12:08 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:ORCHID CAREFACILITY NUMBER:
392700971
ADMINISTRATOR/
DIRECTOR:		CHAN, MING HIMFACILITY TYPE:
735
ADDRESS:421 E BANBURY DRTELEPHONE:
(415) 321-0868
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 4CENSUS: 4DATE:
07/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:09 AM
MET WITH:Chan M.TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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
On 7/8/2024, LPA Johnson arrived at the care facility and met with to conduct a case management visit into an incident report received regarding an AWOL. The care facility did report and have informed all appropriate parties and agencies.

On R1 AWOL 'd 7/3/2024 from the facility, R1 was returned by a neighbor, R1 fled from staff on foot. R1 was gone for 20 minutes. Staff notified the administrator, and called the Department. The facility requested to have a special meeting to address the need for additional services.

R1 is currently back at the facility and is being monitored with additional support. The meeting for VMRC is set for 7/9/2024.

LPA Johnson obtained copies of residents file information.

No deficiencies cited during this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
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 1