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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 12/31/2021
Date Signed: 12/31/2021 03:10:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
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: 5DATE:
12/31/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Lana Somporn TIME COMPLETED:
03:30 PM
NARRATIVE
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On December 31, 2021, Licensing Program Analyst (LPA) Komal Charitra and Jaime Vado conducted an unannounced case management visit in relation to the COVID-19 outbreak that occurred in November 2020 throughout January 2021. LPAs were greeted by Administrator, Lana Somporn and explained the purpose of the visit. LPAs were not screened at the front entrance.

On November 29, 2020, during a telephone meeting between APA Cystal Moore, Regional Manager (RM) Vivien Helbling, and Licensing Program Manager (LPM) Julio Montes, Administrator Lana Somporn indicated that resident had died of choking rather than COVID-19 which implied potential lack of supervision. The Department investigated and found that the resident did die due to COVID-19 and not choking. The investigation also found that the administrator had been neglectful and unable to adhere to county directives and recommendations and therefore contributed to resident being exposed to Coronavirus.

Due to the Administrator not following infection control guidance, and lack of staff training and oversight, this caused the Cornonavirus to enter both facilities; Orchid Villa and Orchid Lan (facility no. 415600667). A temporary manager had to be put in place to manage both facilities through the Coronavirus outbreak and bring both facilities back into compliance.

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.

Report is reviewed with Administrator, Lana Somporn and a copy will be provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ORCHID VILLA RESIDENTIAL CARE
FACILITY NUMBER: 410508820
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/01/2022
Section Cited

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Administrator Qualifications: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...
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This requirement is not met as evidence by: Due to lack of administrator qualifications, a temporary manager (TM) was needed to be imposed to help manage both of licensee’s facilities. The TM helped bring both facilities in compliance with both County and State regulations and help recover from the COVID-19 outbreak.
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Type A
01/01/2022
Section Cited

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Peronal Rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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This requirement is not met evidence by: Due to the facility having a COVID-19 outbreak from November 2020-January 2021, a temporary manager had to be imposed because licensee failed to comply to County and State guidance’s and directives which poses/posed a potential health, safety or personal rights risk to persons 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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2021
LIC809 (FAS) - (06/04)
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