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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 11/23/2021
Date Signed: 11/24/2021 09:15:13 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: DATE:
11/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Anotonia PeraltaTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day at 1430hrs, Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted a joint case management investigation visit in response to an incident report received on 11/22/2021 where a resident left the facility unsupervised. LPA's met with caregiver Antonia Peralta and explained the purpose of today's visit.

During today's investigation visit LPAs spoke to staff, license, and reviewed the physician's report of R1. According to the physician's report the resident is not allowed to leave the facility unsupervised and has wandering behavior according to the physicians report. This physicians report is dated within one year of today's date making it accurate according to licensee. The resident was able to leave the facility unsupervised despite the alarm system that are in place. The resident was returned by Menlo Park Police Department on the same day within a few hours of him leaving the facility unsupervised. Resident was unharmed and returned safely to the facility.

Based on incident report received, interviews conducted, and resident documents reviewed citation is issued under California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC809D.

Report is reviewed with caregiver Anotonia Peralta..
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2021
Section Cited

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Care of Persons With Dementia - There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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This requirement has not been met as evidenced by: R1 was able to leave the facility without supervision and was later returned to the facility by Menlo Park Police Department on the same day the resident eloped from the faciilty.
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POC shall be received by due date of 11/24/2021.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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