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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:18:34 PM


Document Has Been Signed on 03/10/2022 04:18 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:
03/10/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator, Lana Somporn TIME COMPLETED:
03:50 PM
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On March 10, 2022 Licensing Program Analyst (LPA) Komal Charitra and Jaime Vado conducted an unannounced Case Management POC visit to follow up on a non-compliance conference meeting from February 14, 2022. LPAs were greeted by Administrator/Licensee, Lana Somporn and explained the purpose of the visit. LPAs were screened at the entrance.

On February 14, 2022, San Bruno Regional Office conducted a non-compliance conference meeting with Licensee/ Administrator Lana Somporn. 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.

Although facility administrator was able to provide LPAs with a plan of corrections made by the temporary manager when she was in place, it does not meet the requirement specified by the Department during the non-compliance conference. LPA will request an updated written plan of action to be submitted by 3/15/22.

No citations issued during this visit. LPAs reviewed the report with 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: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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