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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
410508820
Report Date:
02/24/2021
Date Signed:
02/24/2021 03:10:57 PM
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 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:
5
DATE:
02/24/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Lana Samporn
TIME COMPLETED:
03:00 PM
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On 02/24/2021 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management tele-inspection. LPA met with licensee Lana Somporn and explained the purpose of today's tele-inspection.
LPA discussed with the licensee the vaccine status of the facility. Vaccine status is discussed and details are provided to LPA.
No citations issued.
Report is discussed with the licensee and how this report will be delivered to facility. LPA is sending a copy of this report to facility via facility email address. Licensee agrees to acknowledged receipt of email.
SUPERVISOR'S NAME:
Julio Montes
TELEPHONE:
(650) 272-7906
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/24/2021
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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