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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 12/31/2020
Date Signed: 12/31/2020 11:43:14 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: 4DATE:
12/31/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Lana SompornTIME COMPLETED:
11:18 AM
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On 12/31/20 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, Licensee Lana Somporn, and Infection Preventionist Ricardo Aban.

The Department representatives toured the facility and observed proper signage at the entry point, proper screening documents, and signs posted throughout the facility. Residents rooms and bathrooms were observed with hand washing signs posted. Observed in the living room area were 3 recliners, less than 6ft apart, which PCC Helen Shi advised Lana to block the middle recliner so the other 2 are 6ft apart, maintaining social distancing. LPA and PCC also observed Lana Somporn performing donning and doffing of PPE.

Lana Somporn stated that Ricardo Aban will be on call staff, and Lana Somporn will send an updated LIC 500.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
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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