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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508820
Report Date: 12/31/2021
Date Signed: 12/31/2021 03:08:48 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 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: 5DATE:
12/31/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Lana SompornTIME COMPLETED:
03:30 PM
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On December 31, 2021, Licensing Program Analyst (LPA) Komal Charitra and Jaime Vado conducted an unannounced Plan of Correction (POC) visit to observe and clear deficiency cited on November 23, 2021. LPAs were greeted by Administrator, Lana Somporn, and explained the purpose of the visit.

On November 23, 2021, LPAs cited facility for California Code of Regulation (CCR) 87705(a)(4) Care Persons with Dementia due to an Incident that occurred on November 20, 2021. LPAs received the POC from Administrator and observed the following; facility now has one enter and exit gate located on Santa Rita Avenue. LPAs also observed the new and louder alarms that were installed at every exit door and a motion sensor device located by the back door. Administrator was able to show LPAs camera heads that will be installed outside around the house.

According to the Administrator, the resident is allowed to go out to take walks but only with a caregiver. Due to the weather conditions right now, the resident has not been going out to take walks. According to the Administrator, the resident's primary physician was notified of the incident and adjusted his medication and according to licensee interview, on 12/31/2021, "medications are working."

LPAs reviewed the report with Lana Somporn and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021
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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