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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600667
Report Date: 12/31/2021
Date Signed: 12/31/2021 12:21:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200819134830
FACILITY NAME:ORCHID LANFACILITY NUMBER:
415600667
ADMINISTRATOR:SOMPORN, LANAFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 234-9987
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 2DATE:
12/31/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susie HerreraTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Unqualified staff assisting resident
Licensee failing to follow prescriptions/physicians orders
Licensee failing to keep current resident and staff files
INVESTIGATION FINDINGS:
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3
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5
6
7
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9
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12
13
On this day at 0915hrs Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannounced complaint investigation visit to deliver the findings for the above allegation. LPAs met with caregiver Susie and explained purpose of today's visit. LPAs observed two residents and the one caregiver on site.

During the course of the investigation, LPA Vado conducted interviews and reveiwed documentation. As a result of a Temporary Mangager (TM) needing to be assigned to this facility, and the licensee's other facility Orchid Villa #410508820, it was found that several staff were not trained properly and inaccurate staff and resident files were observed by the TM and LPA. As a result of insufficient training COVID was allowed to enter both licensee's facilities which showed a lack of training for staff in regards to infection control and a TM was needed to assist in the management of both facilities. Prescriptions and physicians orders were not being followed as observed by TM where certain medications were not being provided to residents as a result of the licensee indicating that the medications did not help the resident's and loose pills were observed in another container which contained said meidations that were not labled and staff indicated that they were directed to not provide by the licensee. These allegations are substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Report is reviewed by caregiver Susie.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200819134830

FACILITY NAME:ORCHID LANFACILITY NUMBER:
415600667
ADMINISTRATOR:SOMPORN, LANAFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 234-9987
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 2DATE:
12/31/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susie HerreraTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
No overnight care for residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day at 0915hrs Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannounced complaint investigation visit to deliver the findings for the above allegation. LPAs met with caregiver Susie and explained purpose of today's visit. LPAs observed two residents and the one caregiver on site.

During the course of the investigation, LPA Vado conducted interviews and reveiwed documentation. It was discovered that there is one staff that is present at overnight hours for resident care. This staff person is not considered wake staff but did provide care to a resident when needed and to assist with incontenence care. This staff logged his time via notepad and provided to licensee to show times he provided care for record keeping and payment for the care. This staff may or may not have been trained properly and may have not been complete with his care at times. This allegation is unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with Susie.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20200819134830
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 LAN
FACILITY NUMBER: 415600667
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/01/2022
Section Cited
CCR
87465(c)(2)
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7
Incidental Medical and Dental Care- If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87465(c)(2). Licensee shall ensure in writing that all physicains order and prescritions are followed per the order or prescription.
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This regulation has not been met as evidenced by: LPA and Temporary Manager observed prescriptions not being followed as it was observed loose pills with no labeling and was indicated by staff and licensee that the pills belonged to the residents but were not being given due to licensee decision.
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9
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14
 POC due in CCLD by due date
Type B
01/07/2022
Section Cited
CCR
87411(d)
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Personnel Requirements - All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance
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Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87411(d). Licensee shall ensure that all staff are trained properly and shall use training materials and/or approved vendors to provide the training for staff.
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This regulation has not been met as evidenced by: LPA and Temporary Manager observed inaccurate training records and discovered that not all staff are trained. As a result of insufficent training COVID was able to enter facility.
8
9
10
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12
13
14
 POC due in CCLD by due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/31/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20200819134830
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 LAN
FACILITY NUMBER: 415600667
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2022
Section Cited
CCR
87412(a)
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2
3
4
5
6
7
Personnel Records - The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
1
2
3
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5
6
7
Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87412(a).
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9
10
11
12
13
14
This regulation has not been met as evidenced by: LPA and Temporary Manager observed inaccurate training records and discovered that not all staff are trained. As a result of insufficent training COVID was able to enter the facility.
8
9
10
11
12
13
14
1
2
3
4
5
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7
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2
3
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7
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7
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2
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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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/31/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4