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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700971
Report Date: 11/13/2023
Date Signed: 11/13/2023 04:37:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230913120511
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: 3DATE:
11/13/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ming (Ryan) Him Chan TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility failed to provide level of care
Facility failed to provide lunch for resident


INVESTIGATION FINDINGS:
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On 11/13/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue an investigation in to the above listed allegations. LPA Jensen met with Ming Him Chan and explained the purpose of today's visit.

During the course of the investigation LPA Jensen interviewed the Licensee/Administrator and a staff member that was on duty at the time of the incidents in question. LPA Jensen also reviewed the staff file for Resident 1 (R1).

Facility failed to provide level of care:
The Licensee and staff 1 (S1) both confirmed that there was an occasion in September 2023 where Resident 1 (R1) went to Day Program and needed a clean change of clothing. The Licensee and staff further confirmed that soiled clothing was brought to Day Program in error.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20230913120511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ORCHID CARE
FACILITY NUMBER: 392700971
VISIT DATE: 11/13/2023
NARRATIVE
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The Licensee and S1 both confirmed that R1 regularly needs to have a change of clothing available as a result of a medical condition. The IPP for R1 states that R1 is working to increase personal care skills and complete tasks independently however the care home will provide assistance as needed. Based on the interviews conducted there is no dispute R1 was provided soiled clothing at Day Program therefore the allegation of " facility failed to provide level of care" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Facility failed to provide lunch for resident:
LPA Jensen interviewed the Licensee and S1. Both the Licensee and S1 confirmed that there was an occasion wherein R1 was sent to Day Program without lunch. The day Based on the interviews conducted there is no dispute that R1 was sent to Day Program without lunch on at least once occasion therefore the allegation of "facility failed to provide lunch for resident is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

In the days following the incident wherein R1 was sent to Day Program without a lunch and was brought soiled clothing by staff, the facility has implemented measures to prevent these issues from reoccurring. The facility has created a check list that staff uses that includes verifying residents have brought lunch with them to program and that R1 also brings extra sets of clothing that have been verified to be clean.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6.

An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230913120511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ORCHID CARE
FACILITY NUMBER: 392700971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2023
Section Cited
CCR
80076(a)(1)
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7
Food Service
All food shall be ... in the quantity necessary to meet the needs of the clients. This requirement was not met as evidenced by:
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The Licensee has implemented measures to verify compliance with this regulation. No further Plan of Correction is needed.
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Based on the Licensee's and S1's confirmation that R1 went to Day Program without lunch. This poses a potential risk to the health, safety and poersonal rights of residents in care.
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Type B
11/14/2023
Section Cited
CCR
85077(a)
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7
Personal Services
Licensees shall provide necessary personal assistance and care, as indicated in the needs and services plan, with activities of daily living including but not limited to dressing, eating, and bathing. This requirement was not met as evidenced by:
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The Licensee has implemented measures to verify compliance with this regulation. No further Plan of Correction is needed.
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Based on the Licensee's and S1's confirmation that R1 was brought soiled clothing to change in to at Day Program. This poses a potential risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230913120511

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: 3DATE:
11/13/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ming (Ryan) Him ChanTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
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9
Facility failed to provide level of care for infected eye
INVESTIGATION FINDINGS:
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On 11/13/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue an investigation in to the above listed allegation. LPA Jensen met with Ming Him Chan and explained the purpose of today's visit.

LPA Jensen interviewed the Licensee/Administrator and staff 1 (S1). Both advised that the Day Program notified the facility that resident 1 (R1) had eye redness. Facility staff believed the cause to be tiredness and irritation from prolonged use of a video monitor. The following week the Day Program again reported R1 to have eye redness and at that time R1 was brought to urgent care and commenced treatment for an infection. LPA Jensen reviewed the medical records related to this incident. Based on the interviews conducted and records reviewed it is unclear whether the facility pursued care in a timely manner or not therefore the allegation of "facility failed to provide level of care for infected eye" is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230913120511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ORCHID CARE
FACILITY NUMBER: 392700971
VISIT DATE: 11/13/2023
NARRATIVE
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3
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A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5