<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700869
Report Date: 07/05/2023
Date Signed: 07/05/2023 01:26:54 PM


Document Has Been Signed on 07/05/2023 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ORANGEBURG MANORFACILITY NUMBER:
502700869
ADMINISTRATOR:ARBIOS, MARIEFACILITY TYPE:
740
ADDRESS:1248 NELSON AVENUETELEPHONE:
(209) 527-2222
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:90CENSUS: 33DATE:
07/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Resident Care Coordinator Andrea Eldridge TIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jason Lund & Licensing Program Manager (LPM) Steven Richardson arrived unannounced to do a case management visit. LPA Lund met with Resident Care Coordinator Andrea Eldridge and explained the reason for the visit.

LPA Jason Lund received two reports from Modesto Fire Department dated 2/13/2023 & 5/31/2023. Report dated 2/13/2023 had five violations exit doors and door hardware shall be maintained operational at all times, exits and exit paths shall not be obstructed or obscured, unapproved locking/latching devices shall be removed, remove door stops and other obstructions to fire doors and maintain premises free from conditions that would contribute to life hazard or rapid spread of fire. Report dated 5/31/2023, unapproved locking/latching devices shall be removed- the facility put in a screw in a total of eight residents sliding glass doors rooms (24, 25, 26, 27, 29, 30, 33, 34), keeping the residents from being able to open the sliding glass doors and being able to exit in case of a fire.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Civil penalties were given.

An exit interview was held with Resident Care Coordinator Andrea Eldridge. A copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/05/2023 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ORANGEBURG MANOR
FACILITY NUMBER: 502700869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/06/2023
Section Cited
CCR
87705(c)(1)

1
2
3
4
5
6
7
Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(1)The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers......
1
2
3
4
5
6
7
The facility will get in complaice with title 19.
8
9
10
11
12
13
14
This was not met as evidenced by: The facility has two reports from Modesto Fire Department dated 2/13/2023 & 5/31/2023 has six Regulations title 19 that required complaince.This poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2