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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700971
Report Date: 10/23/2024
Date Signed: 10/23/2024 11:52:26 AM

Document Has Been Signed on 10/23/2024 11:52 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
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:
10/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:52 AM
MET WITH:Ben Jiang and Patty LiangTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 10/23/2024, LPA Johnson arrived at the care facility and met with to conduct a case management visit into an incident report received regarding a medical emergency.
On 10/17/2024 R1 called 911 without notifying the staff. R1 was taken to the ER for neck pain and was released by the ER with instruction to follow-up with his primary care doctor. R1 had a tele-care appointment with his PCP with no changes to his medication or the care plan. Staff notified the administrator, and called the Department.

Today 10/23/2024, LPA was informed that R1 called 911 again on yesterday 10/22/2024 complaining of chest pain. R1 was taken to St. Joseph's hospital and released with no new orders. Staff notified the administrator, and called the Department.

R1 is currently back at the facility and is being monitored with additional support.

No deficiencies cited during this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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