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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 12/02/2020
Date Signed: 12/03/2020 11:29:36 AM

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: 4DATE:
12/02/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Cantoria - Temporary ManagerTIME COMPLETED:
12:00 PM
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Community Care Licensing Division - San Bruno Regional Office conducted a follow-up Technical Assistance tele-inspection visit today. Present in today's tele-inspection were Licensing Program Analyst (LPA) Gladys Kuizon, Regional Manager (RM) Vivien Helbling, Assistant Program Administrator (APA) Stacy Barlow, Program Clinical Consultant (PCC) Helen Shi and Temporary Manager (TM) Maria Cantoria.

On 12/01/2020 at 10:00 am, PCC, RM, APA, Acting APA Krystall Moore, and LPA Jaime Vado conducted a tele-inspection with TM and licensee, Lana Somporn, to check the facility's health and safety protocols in regards to COVID-19.

The following were observed during the physical plant inspection:

1. On 12/01/2020, the garage, which houses facility cleaning supplies and other toxic materials, was observed unlocked and accessible to residents. According to TM, she instructed the licensee to keep the garage door locked at all times. Today, a new garage door knob was observed being installed. New door knob is equipped with a pin pad.

2. On 12/01/2020, garage was observed disorderly. A large pile of items was located in the center of the garage. TM was attempting to locate paper supplies from the pile. The laundry washer and dryer were located in the garage. On top of the laundry machine, two bundles of bananas were observed along with laundry items. Today, garage was observed organized, with paper products, disinfectants, and food items stored in separate areas.

3. On 12/01/2020, the centrally stored medication storage was inspected. It was observed that the centrally stored medication and destruction record (CSMDR) was not current. Last record dated on 09/26/2020.
Continued, see LIC 809-C, page 2.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
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 4
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
VISIT DATE: 12/02/2020
NARRATIVE
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There were no physician's orders on file upon the Department's request for medications such as TUMS, Robitussin and vitamins which were stored in the central medications cabinet. Today, TM stated she had contacted all residents' physician's to request copies of prescriptions.

4. On 12/01/2020, the backyard and front yard area were observed cluttered with piles of leaves and some bags of soil in the front yard and walkway to the drive way. Today, the yard was observed cleared of clutter.

Today, the following were recommended by PCC to be completed by the facility:
1. Place a trash bin with lid by the main exit inside the facility where staff can dispose PPEs prior to exiting the facility.

2. Provide individual plastic or paper bags for staff to store re-usable PPEs (e.g. face shield, N-95 masks) when exiting the facility for breaks during their shift.

3. N-95 masks can only be re-used by staff for one shift or one day. A new N-95 mask must be provided daily.

4. All staff must wear full Personal Protective Equipment (PPE) gear including face mask, face shield, long sleeved gowns and gloves. This includes staff who have previously tested COVID-19 positive and have already been cleared.

5. Dirty laundry must be collected and brought to the laundry area in closed receptacles or bags and kept separate from clean, sanitized laundry to avoid recontamination. This separation of dirty and clean area must be clearly labelled or marked.

6. Toxic materials storage: separate hand sanitizers from cleaning supplies such as bleach and detergents.

7. Facility to send the following to CCLD: facility floor plan, centrally stored medication log for all residents, copy of current staff schedule (LIC 500), and Infection Control and Mitigation Plan.

Deficiencies were cited today. See LIC 809-D. Report was discussed with Temporary Manager and a copy was provided via email for signature. Appeal rights were provided.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 12/02/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2020
Section Cited

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87309 Storage Space. (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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On 12/01/20, facility's garage door was observed unlocked. Bleach, ammonia, laundry detergents and other toxic materials were observed in the garage. This posed an immediate risk to the health and safety of residents in care.
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Type A
12/03/2020
Section Cited

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87465 Incidental Medical & Dental Care. (e)For every prescription & nonprescription PRN medication ...there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.
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This requirement was not met as evidenced by: On 12/01/20, during inspection of central medication storage, medications with no corresponding physician's orders on resident's files were observed. This poses an immediate risk to the health 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.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 12/02/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2020
Section Cited

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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by:
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During 12/01/20 inspection, kitchen was observed cluttered, garage was observed disorderly, and front and backyards were cluttered with leaves and bags of soil. This poses a potential risk to the safety 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.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4