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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 10:47:26 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:Case Management - OtherUNANNOUNCEDTIME 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 case management visit. LPAs met with licensee Lana Sompron and explained purpose of today's visit.

LPA Vado spoke to Lana regarding the recent DOL judgement and details regarding it. She provided LPA with documents from DOL to observed. She has completed her requirements at this time regarding this. She will provide LPA electronic copies of these documents per LPAs request. She will get assistance with these items to send to LPA today. LPAs toured facility and observed utilities and food supplies are in place. According to licensee there is no issues with her facilities at this time as the issue has been taken care of for several months.

No citations issued on this day.
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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