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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410508820
Report Date: 12/31/2021
Date Signed: 12/31/2021 03:39:38 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-20200819133125
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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lana SompornTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Unqualified staff assisting resident
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 Lan #415600667, it was found that several staff were not trained properly and inaccurate staff files were observed by the TM and LPA. As a result of insufficient training COVID was allowed to enter both licensee's facilities which showed that staff were unqualified in regards to infection control which lead to a TM neededing to assist in the management of both facilities in order for them to get back within compliance and assist in the recovery from the COVID outbreak. It was also discovered that the licensee relied on the staff to self enforce infection control wihtout proper oversight and training. This allegation is 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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (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)
Page: 1 of 3
Control Number 14-AS-20200819133125
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 B
01/07/2022
Section Cited
CCR
87411(d)
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Personnel Requirements - All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance
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Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87411(d). Licensee shall ensure that all staff are trained properly and shall use training materials from approved vendors to provide the training for staff in infection control and daily caregiving.
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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 properly. As a result of insufficent training COVID was able to enter facility due to the licensee not enforcing infection control procedure with staff.
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POC to be received in CCLD by due date
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (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-20200819133125

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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lana SompornTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility failing to meet the needs of overnight care of incontinent residents
More than 15 hours between meals (dinner - breakfast)
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. It is discovered that the meals of the resident are flexible per each resident's personal preference and schedule according to staff and licensee interviewed. There is a formal breakfast and dinner time but each resident can eat at their preferred times, thus making it appear that meal times between dinner and breakfast exceed 15hrs. Some residents eat dinner earlier or later than others as well as breakfast. In regards to facility meeting the needs of overnight incontinence care, it is discovered that there is staff tpresent at overnight hours for resident care. The licensee resides in this facility as well as another staff person. Staff is not considered wake staff but do provide care to residents when needed and to assist with incontenence care. Staff may or may not have been trained properly and may have not been complete with this type of care at times but there are indications some care was provided per interviews. 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (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)
Page: 3 of 3