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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700869
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:59:21 PM


Document Has Been Signed on 04/18/2024 02:59 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 38DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director Jennifer WhiteleyTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit, met with Executive Director Jennifer Whiteley and explained the purpose of the visit. Census 38

LPA Lund & Executive Director Jennifer Whiteley toured/inspected the facility. The facility is a single-story main building that consists of a main lobby, T.V. room, activity room, dining and kitchen area, laundry area, medication room and open courtyard area. LPA Lund observed the residents’ bedrooms are either private or shared bedrooms and there are both private and shared bathrooms. Residents’ bathrooms are equipped with non-skid surfaces and grab bars as required. LPA observed the facility to be free of odor, clean and in good repair. LPA Lund observed sufficient furniture and lighting throughout the facility. This facility does not have a pool or bodies present. LPA Lund observed sufficient 7- day non-perishable and 2- day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA Lund observed centrally stored medications and toxins are kept locked and inaccessible to residents. The first aid kit was checked and is complete. LPA Lund reviewed four staff & four residents files and were in compliance.

No deficiencies were observed and cited during this visit. Exit interview held with Executive Director Jennifer Whiteley and a copy of report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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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