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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:09:28 PM


Document Has Been Signed on 03/10/2022 04:09 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: 5DATE:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Lana SompornTIME COMPLETED:
04:30 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 this day at 1515 hours, Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra conducted an unannounced case management inspection visit in response to an incident report received on 2/28/2022 regarding a resident leaving the facility unsupervised. LPAs met with licensee Lana Somporn and explained purpose of today's visit.

The incident report detailed that the resident left the facility unsupervised by staff. There was a perimeter search conducted but staff were unable to locate. Local police department was contacted by a neighbor who found the resident on their property. LPAs inspected the room of the resident and observed the physicians report of the resident. This resident did leave the facility within a one year time frame and this is a repeat violation. The resident left the facility unsupervised back in 11/2021 and occurred again on 2/25/2022.

Based on incident report received, interviews conducted, and resident documents reviewed citation is issued under California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC809D.

A Civil Peanlty is being assessed in the amount of $250 for the repeat violation on attached LIC421FC.

Citation is issued on this day on attached LIC809D.

Report is reviewed with licensee Lana Somporn. Appeal right given.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
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)
Page: 1 of 2


Document Has Been Signed on 03/10/2022 04:09 PM - It Cannot Be Edited

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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited

1
2
3
4
5
6
7
Care of Persons With Dementia - There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
8
9
10
11
12
13
14
This requirement has not been met as evidenced by: R1 was able to leave the facility without supervision again on 02/25/2022 and was later located by a neighbor whoe contacted Menlo Park Police Department. The resident returned to the facility on the same day.

This is a repeat violation within a one year time frame. A Civil Peanlty is assessed in the amount of $250 for the repeat violation and can be found on attached LIC421FC
8
9
10
11
12
13
14
POC shall be received by due date of 03/11/2022.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2