410508820-12-31-2021-14-AS-JMOS-CDTTGM-20220425144323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410508820
Report Date: 12/31/2021
Date Signed: 12/31/2021 03:43:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200819081717

FACILITY NAME:	ORCHID VILLA RESIDENTIAL CARE		FACILITY NUMBER:	410508820
ADMINISTRATOR:	SOMPORN, LANA T.		FACILITY TYPE:	740
ADDRESS:	1239 MIDDLE AVENUE		TELEPHONE:	(650) 325-5812
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	6	CENSUS:	DATE:	12/31/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lana Somporn		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Licensee failing to follow prescriptions/physician orders
Licensee failing to keep current resident and staff files

INVESTIGATION FINDINGS:

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On this day at 1300hrs Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannounced complaint investigation visit to deliver the findings for the above allegation. LPAs met with licensee and explained purpose of today's visit.

During the course of the investigation, LPA Vado conducted interviews and reveiwed documentation. As a result of a Temporary Mangager (TM) needing to be assigned to this facility, and the licensee's other facility Orchid Villa #4105600667, it was found that inaccurate staff files were observed by the TM and LPA. It was also found that prescriptions and physicians orders were not being followed as observed by the TM where certain medications were not being provided to residents, or prescriptions not being followed, as a result of the licensee indicating that the medications did not help the resident's and loose pills were observed. These allegations are substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20200819081717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 01/07/2022 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care- If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87465(c)(2). Licensee shall ensure in writing that all physicains order and prescritions are followed per the order or prescription.
	8 9 10 11 12 13 14	This regulation has not been met as evidenced by: LPA and Temporary Manager observed prescriptions not being followed as it was observed loose pills and certain prescriptions are not being followed per licensee's own discretion.	8 9 10 11 12 13 14	POC due in CCLD by due date
Type B 01/07/2022 Section Cited CCR 87412(a)	1 2 3 4 5 6 7	Personnel Records - The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.	1 2 3 4 5 6 7	Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87412(a). Licensee shall ensure that all staff records are complete and accurate. All staff are to have a file on site to review which includes training.
	8 9 10 11 12 13 14	This regulation has not been met as evidenced by: LPA and Temporary Manager observed inaccurate training records and discovered that not all staff are trained. As a result of insufficent training COVID was able to enter the facility.	8 9 10 11 12 13 14	POC due in CCLD by due date

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 Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaime Vado

COMPLAINT CONTROL NUMBER: 14-AS-20200819081717

FACILITY NAME:	ORCHID VILLA RESIDENTIAL CARE		FACILITY NUMBER:	410508820
ADMINISTRATOR:	SOMPORN, LANA T.		FACILITY TYPE:	740
ADDRESS:	1239 MIDDLE AVENUE		TELEPHONE:	(650) 325-5812
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	6	CENSUS:	DATE:	12/31/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lana Somporn		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Personal Rights – Licensee insert finger in resident’s private area to induce bowel movement
Licensee fed a resident in the bathroom

INVESTIGATION FINDINGS:

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On this day at 1300hrs Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannounced complaint investigation visit to deliver the findings for the above allegation. LPAs met with licensee and explained purpose of today's visit.

During the course of the investigation, LPA Vado conducted interviews and reviewed documentation. LPA discovered differences in staff and licensee statements that would prove or disprove that this occurred. Witness account indicated they were outside of the restroom where this happened and not up close in regards to the possible personal rights violation. In regards to feeding, interviews indicated that the resident was not fed but water and a plate were in hand due to the resident needing assistance to the restroom but the plate and or cup of water was brought in. Witness also indicated that they did not see feeding but rather the plate or water in the bathroom as they walked by. There were no other witnesses available to the situation and is one persons word over an other. Resident passed away shortly after and could not be interviewed. These allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with licensee.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
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.

LIC9099 (FAS) - (06/04)

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