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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 12/11/2020
Date Signed: 12/14/2020 10:08:07 AM

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:
12/11/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria CantoriaTIME COMPLETED:
12:00 PM
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On 12/11/20 Licensing Program Analyst (LPA) Chris Hopkins, Regional Manager (RM) Vivien Helbling, and Program Clinical Consultant (PCC) Helen Shi conducted an announced televisit via facetime with Temporary Manager Maria Cantoria along with Administrator Lana Somporn.

The Department representatives toured the facility and observed staff donning and doffing PPE. PCC Helen Shi advised Temporary Manager Maria Cantoria to get more training for staff on how to donn and doff PPE, Maria Cantoria agreed. Temporary Manager Maria Cantoria also expressed concern about shortage of staffing once her and her team's contract is up. LPA and RM asked Administrator Lana Somporn for an updated LIC 500 to be sent 12/14/20.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2020
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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