<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 02/14/2022
Date Signed: 02/14/2022 05:15:12 PM


Document Has Been Signed on 02/14/2022 05:15 PM - It Cannot Be Edited

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: DATE:
02/14/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee, Lana Somporn TIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On February 14, 2022, San Bruno Regional Office conducted a non-compliance conference meeting with Licensee/ Administrator Lana Somporn. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Managers, Julio Montes and Brenda Chan, Licensing Program Analyst, Komal Charitra and Muriel Han, Long Term Care Ombudsman, Nicki Manske. Joining Lana Somporn, were 2 daughters; Susan Tilma and Diana Covich and Susan's husband, Triston Tilma.

During non-compliance meeting, the following violations were discussed; Administrator Qualifications, Personal Rights, Incidental Medical and Dental Rights, Care Persons of Dementia, Storage Space and Reporting Requirements.

During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring inspection visits to ensure compliance with this compliance plan of Title 22 regulation.

Licensee was also informed of the serious violations and pending reviews for possible additional civil penalties.

Report is discussed with Administrator and a copy is provided.


SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022
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 1