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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700619
Report Date: 09/17/2021
Date Signed: 09/17/2021 11:33:02 AM

Document Has Been Signed on 09/17/2021 11:33 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:YELLOW ORCHID LLCFACILITY NUMBER:
342700619
ADMINISTRATOR:BHADE, KIRENDEEPFACILITY TYPE:
740
ADDRESS:9470 SEA CLIFF WAYTELEPHONE:
(916) 432-0685
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 5DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aministrator Karen Bhade & Licensee Narinderpal BhadeTIME COMPLETED:
11:45 AM
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On 9-17-21 Licensing Program Analyst (LPA) Tirzah Hubbard and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to conduct a Required – 1 Year inspection. LPA contacted the facility to ask follow up questions in regard to Covid-19. LPA spoke with the Administrator Karen Bhade to ask follow up questions for Covid-19 symptoms. Karen stated, " The facility has not tested positive for Covid-19 in the last 14 days. All residents are vaccinated and all staff are vaccinated at this time". LPA and LPM proceeded to approach the facility to conduct the Annual after the facility was cleared. All required COVID measures were not observed. LPA observed S1 and Administrator not wearing mask upon entry. LPA and LPM asked Administrator and Licensee to put their mask on for the duration of the Annual visit. The Administrator took the temperature of LPA and LPM but did not screen for symptoms. Administrator stated, the facility verbally ask the Covid-19 questions to ensure visitors are negative upon entry after they take temperature. The Administrator and Licensee agreed to create a document that provides the Covid-19 questionnaire to provide proof of each visitors symptoms.
LPA met with Administrator Karen Bhade and Licensee Narinderpal Bhade, and stated the purpose of today’s visit. LPA and LPM were allowed entry into the facility that is licensed to serve a total capacity of 6 clients. LPA interacted with a random number of residents during this visit. The physical plant was tour inside and outside to ensure the safety of the residents. All required furniture were observed. LPA observed residents engaging in activity, wearing a mask and practicing social distancing. LPA observed the facility conducts fire drills monthly. All bedrooms contained a dresser, bed, and night stand. The flooring of the facility has been replaced. LPA observed the thermostat 73*F temperature inside the facility hallway was measured at 74 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 106 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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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: YELLOW ORCHID LLC
FACILITY NUMBER: 342700619
VISIT DATE: 09/17/2021
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The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.

LPA observed there were food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

LPA observed the backyard area in good condition. LPA spoke with caregivers about the cleanliness of the facility.

Mitigation Plan was submitted and approved.

Upon a file review the following items were discussed to be submitted with any changes annually:

Criminal Record Clearances LIC536
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager- Administrator certificate
Emergency Disaster Plan LIC610D


Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, there were no deficiencies cited during this visit. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
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