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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 11/29/2020
Date Signed: 11/29/2020 05:04:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ORCHID VILLA RESIDENTIAL CAREFACILITY NUMBER:
410508820
ADMINISTRATOR:SOMPORN, LANA T.FACILITY TYPE:
740
ADDRESS:1239 MIDDLE AVENUETELEPHONE:
(650) 325-5812
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 3DATE:
11/29/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Lana SompornTIME COMPLETED:
05:15 PM
NARRATIVE
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On 11/14/20 Licensing Program Analyst (LPA) David Marrufo conducted an unannounced case management. LPA met with Lana Somporn via tele-visit due to Covid-19 procedures and explained the purpose of the tele-visit.

Given the present pandemic, this facility is being closely monitored by the local department of health (LDH) and Department of Social Services. This facility is required to submit a daily report (“linelist”) to both, Local Department of Health (LDH) and Community Care Licensing (CCL) specifying any changes related to the pandemic, and to report any epidemic outbreak related issues within 24 hours. The licensee/administrator became aware of the first reported positive case on November 17, 2020, and the first linelist was submitted to the Department on November 28, 2020. During the virtual visit on November 24, 2020 CCL LPA Vado and HFEN Barbara Elenteny observed staff and residents not wearing masks, the facility was not screening incoming staff or visitors, trash bins with no lids, and a lack of general precautions.

Furthermore, earlier today (11:00 AM), CCL representatives (Acting Assistant Program Administrator Moore, Regional Manager Helbling, Program Manager Montes, and Program Analyst Marrufo) held a conference call with the licensee. During the meeting, the licensee/administrator acknowledged to be unaware on the use and the requirements of the linelist and indicated that struggling with the San Mateo County alert system to Public Health for COVID positives and the Department of Social Services’ recommendations and guidance.
Deficiencies were given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Lana Somporn and a copy of this report was sent via email. Appeal Rights will also be sent.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2020
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ORCHID VILLA RESIDENTIAL CARE
FACILITY NUMBER: 410508820
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2020
Section Cited

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Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require. This requirement is not met as evidenced by:
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The licensee failed to submit the required daily linelist to LDH and CCL, which poses a potential health and safety risk to residents in care.
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Type A
11/30/2020
Section Cited

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Personal Rights of Residents in All Facilities - Residents in all residential care facilities for the elderly shall have be accorded safe, healthful and comfortable accommodations, furnishings
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and equipment. This requirement is not met as evidenced by:
Observations that staff and residents not wearing masks, the facility was not screening incoming staff or visitor, trash bins with no lids, and a lack of general precautions, and failure to follow recommendations and guidelines to prevent outbreak.
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be taken in order to prevent outbreak.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ORCHID VILLA RESIDENTIAL CARE
FACILITY NUMBER: 410508820
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2020
Section Cited

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Administrator - Qualifications and Duties - The administrator shall have knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is
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not met as evidenced by:
The licensee/administrator lack of acknowledgement and failure to comply with COVID protocols, recommendations and guidelines.
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CCL, and CDC.

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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.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3