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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700869
Report Date: 07/18/2023
Date Signed: 03/05/2024 11:03:20 AM


Document Has Been Signed on 03/05/2024 11:03 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 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: 32DATE:
07/18/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Regional Vice President of Operations Gregory AwreyTIME 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
A Non-Compliance Conference (NCC) was conducted on this day, 07/18/2023, by the Sacramento South Regional Office via Zoom. The purpose of this NCC meeting was to discuss the high volume of deficiencies/inability of this facility to remain in substantial compliance with the regulations that have occurred within the last 12 months. Present at the meeting were Regional Manager (RM), Stephenie Doub, Licensing Program Manager (LPM), Stephen Richardson, Licensing Program Analyst (LPA), Jason Lund, Lawyer Joel Goldman, Licensee Chris Coulter, Resident Care Coordinator Andrea Eldridge, RCD Jeanine Gaona, Regional Vice President of Operations Gregory Awrey, & Novellus Specialist Rhonda Dolcater. The Non-Compliance Conference process was explained during this meeting to include the administrative process.

Items discussed during the Non-Compliance Conference were:


· The facilities elopements on 1/21/23, 5/17/2023 & 6/15/23
· Six violations from title 19, from Modesto Fire Department dated 2/13/2023 & 5/31/2023 Licensee agreed to do the following in order to bring the facility into compliance no later than the following date 07/28/2023.
· Additional one to two hours of training each month of Dementia Training on different topics for staff.
· Continue quality assurance on building & grounds of the facility once a month.
· Put in monitors in MED TECH room to help ensure monitoring of residents in care.
· Care staff will check on the hour & MED TECHS on the half hour to verify resident count and alarms functioning.
· Have wonder guard on all ambulatory residents in care.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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


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
VISIT DATE: 07/18/2023
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
26
27
28
29
30
31
32
In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action.


Community Care Licensing Department (CCLD) will do the following:
· Increase Monitoring to quarterly visits.
· The facility will have TSP (Technical Support Program) give technical advice to the facility.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with, Novellus Specialist Gregory Awrey and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. In addition, a copy of this report will be sent out certified mail.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2