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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 09/10/2021
Date Signed: 09/10/2021 10:48:20 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:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lana SompornTIME COMPLETED:
11:00 AM
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On this day at 0900, Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra conducted an unannounced infection control annual inspection. LPA met with licensee Lana Somporn and explained purpose of today's inspection. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available. First-aid kit is inspected and is complete. A Disaster and Mass Casualty Plan is observed. There are four residents present and two staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Administrator certificate is viewed as current expiring 09/28/2022. Mitigation plan is current no changes.

The following updated forms are requested to be submitted to CCLD by 09/17/2021:

• Administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan

No deficiencies cited today. Report is reviewed with licensee.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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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