Orchid Facility

Type of visit: Required - 1 Year

At 12:15 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. It is a two story building with 6 bedrooms, 4 bathrooms, kitchen, garage, common areas, and outdoor areas. The second-floor stairway is locked and inaccessible to residents and occupied by the Licensee/Administrator. It has an approved fire clearance for 6 non-ambulatory residents, of which 1 may be bedridden in Bedroom #1. Approved hospice waivers for six (6). The facility uses surveillance cameras on the exterior and in common areas. Kitchen: At approximately, 12:30 PM, LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Surfaces were sanitary and appliances were functional. The stove hood was free of debris. Sharps were locked by the refrigerator, and cleaning solutions locked in the laundry area which was next to the kitchen. The washer and dryer were in good repair and functional. Bedrooms: LPA observed total of six (6) private bedrooms designated for resident use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has an awake staff. Medications: At 12:40 PM, LPA observed medications are centrally stored and locked in the hallway by bedroom # five (5) in a cabinet. LPA reviewed resident's medication and no discrepancies were observed. Continue on LIC 809C Bathrooms: LPA observed four (4) bathrooms and all bathrooms appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and residents' bathroom had non-skid mat. Hot water temperature measured at 119.3°F. Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The facility does not have any garage. Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 12:45 PM they were tested and observed to be operational. LPA tested the dual functioning smoke and carbon monoxide detector in the living room to be operational. When tested, 4 out of 4 detectors functioned simultaneously and 2 out of 2 fire doors closed. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased and inspected on 05/05/2026. Outside areas: At 12:55 PM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. All emergency exit paths were free from obstructions. Between 1:10 PM to 2:45 PM, LPA reviewed records of six (6) residents and two (2) staff. Residents and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. No deficiency cited during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 23, 2026

Type of visit: Required - 1 Year

At 1:30 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. It is a two story building with 6 bedrooms, 4 bathrooms, kitchen, garage, common areas, and outdoor areas. The second-floor stairway is locked and inaccessible to residents. It has an approved fire clearance for 6 non-ambulatory residents, of which 1 may be bedridden in Bedroom #1. Approved hospice waivers for six (6). The facility uses surveillance cameras on the exterior and in common areas. Kitchen: At approximately, 1:40 PM, LPA toured the kitchen area and observed an adequate supply of perishable and non-perishable food in the kitchen. Surfaces were sanitary and appliances were functional. The stove hood was free of debris. Sharps were locked by the refrigerator, and cleaning solutions locked in the laundry area which was next to the kitchen. The washer and dryer were in good repair and functional. Bedrooms: LPA observed total of six (6) private bedrooms designated for resident use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has an awake staff. Medications: At 1:45 PM, LPA observed medications are centrally stored and locked in the hallway by bedroom # five (5) in a cabinet. Bathrooms: LPA observed four (4) bathrooms and all bathrooms appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and residents' bathroom had non-skid mat. Hot water temperature measured at 116.8°F. Continue on LIC809-C Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The facility does not have any garage. Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 1:50 PM they were tested and observed to be operational. LPA tested the dual functioning smoke and carbon monoxide detector in the living room to be operational. When tested, 4 out of 4 detectors functioned simultaneously and 2 out of 2 fire doors closed. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased and inspected on 1/25/2025. Outside areas: At 1:55 PM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. All emergency exit paths were free from obstructions. Between 2:10 PM to 3:20 PM, LPA reviewed records of four (4) residents and two (2) staff. Client and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. No deficiency cited during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 19, 2025

Type of visit: Prelicensing

At 9:30 AM, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Ida Fahimi, Administrator. LPA conducted an entrance interview with the Administrator. At the time of this visit LPA did observe six (6) residents present in the facility. Fire Clearance dated 01/08/2024 and received for five (5) non-ambulatory and one (1) bedridden resident. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The facility is a double story building and only downstairs will accommodate residents in care. Upstairs of the facility is for staff use only. LPA toured the physical plant inside and outside and observed the following: KITCHEN: At 9:40 MA, LPA toured the kitchen. The kitchen area is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in the kitchen in a cabinet. LAUNDRY ROOM: The laundry room is next to the kitchen. LPA observed the washer and dryer are in good repair. The laundry room has a cabinet where the laundry detergents and other cleaning supplies are locked and inaccessible to residents in care. BEDROOMS: At 9:45 AM, LPA observed six (6) private bedrooms for resident’s use only. The facility has two (2) bedrooms upstairs and it is designated for staff us only. LPA observed all bedrooms properly furnished with beds, dressers and required bedding, chest drawer, and linen. The bedrooms have sufficient closet space and have sufficient lighting. Facility will have a live-in staff at the facility. LPA did not observe any obstruction or hazard. Continue on LIC 809C BATHROOMS: At 9:55 AM, LPA observed two (2) full bathrooms and two (2) half bathrooms. Bedroom # one (1) has an attached half bathroom, and bedroom # four (4) also has an attached half bathroom. All bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed to have an appropriate non-skid mat. At 9:56 AM, the water temperature was noted at 115.2°. COMMON AREAS: LPA observed all common area to be clean in good repair. The facility maintains a comfortable temperature at 74°F. The living room and dining rooms were properly furnished. No obstructions and or tripping hazards throughout the facility. The living room has a screened fireplace. There is a dinning table which can accommodate six (6) residents. MEDICATION: Facility has medication that require refrigeration and LPA observed in a locked box in the fridge separate from food. Medications that do not require refrigeration are centrally stored and locked in the hallway by bedroom # five (5) in a cabinet. SURROUNDING GROUNDS: The facility has a backyard and has sufficient space. LPA observe appropriate outdoor furniture, and a covered shaded area for residents. Facility has extra storage area where extra supplies and PPE are stored. There was an additional storage where extra emergency food and other toxins are stored and locked. The facility has two (2) extra bedrooms that are used by Administrator and observed to be locked and inaccessible to residents in care. There is no swimming pool or any bodies of water at the facility. All emergency exit paths were free from obstructions. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors were located throughout the facility, and at 10:10 AM they were tested and observed to be operational. LPA tested the dual functioning smoke and carbon monoxide detector in the living room to be operational. When tested, four (4) out of four (4) detectors functioned simultaneously and two (2) out of two (2) fire doors closed. At 10:12 AM, LPA observed a fully charged fire extinguisher in the kitchen. It was purchased and inspected on 09/09/2023. Continue on LIC 809C Between 10:40 AM, to 11:10 am, LPA reviewed records of two (2) residents and two (2) staff. LPA observed all records are current and up to date. LPA will inform CAB Analyst for license approval. Component III was conducted with the Administrator. Pursuant to Title 22, the facility is compliant to regulation, and ready for license. This report will be forwarded to the Centralized Application Bureau (CAB). The applicant will be notified by the CAB Analyst when their license is approved. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 6, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Ida Fahimi Interview Method: Telephone interview On April 11, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staffing requirements & Training 3. General provisions / facility readinessthe state’s words, verbatim · CDSS document, Apr 11, 2024