The Orange Manor

Type of visit: POC

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/22/2022. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who contacted facility administrator (AD) Aida Martires. For today's visit, LPA De Perio verified that there are 5 residents in care of which 3 are on hospice and one staff on duty. On 11/22/22, facility did not ensure that 3 out of the 4 staff files reviewed, had the required 20-hours of annual training, which poses an immediate health and safety or personal rights risk to persons in care. *Deficiency cited under Title 22 Regulation 1569.625(b)(2) pertaining to Staff Training has been CLEARED. Licensee has submitted proof of the completed required staff training to CCL and assigned LPA on 11/23/22. Licensee has complied with the terms of the POC. On 11/22/22, facility did not ensure that clearance for one of the staff present at the facility was received, which poses an immediate health, safety or personal rights risk to persons in care. *Deficiency cited under Title 22 Regulation 87355 pertaining to Criminal Record Clearance has been CLEARED. Licensee has submitted proof of the completed clearance and background check to CCL and assigned LPA on 11/23/22. Licensee has complied with the terms of the POC. For this visit, no citations were issued and no deficiencies were issued. LPA De Perio conducted an exit interview with AD Martires and a copy of this report and cleared POC letter was provided to the facility.the state’s words, verbatim · CDSS document, Dec 1, 2022

Allegation investigated: Facility staff are not properly trained. Facility staff are not background checked and associated to facility.

Licensing Program Analysts (LPAs) Celine De Perio and Joseph Alejandre made an unannounced 10-day visit to this facility to conduct an investigation for the complaint received on 11/17/2022 and to deliver the findings for the allegations indicated above. LPAs De Perio and Alejandre arrived to facility at 8:03 AM, and explained reason for visit and was greeted and granted entry by facility administrator (AD) Aida Martires. Upon arrival, LPAs De Perio and Alejandre conducted a tour of the interior portion of the facility with AD Martires. For today's visit, there are a total of 6 residents in care of which 3 are on hospice and 2 staff members on duty. On today’s visit, LPAs De Perio and Alejandre conducted file reviews, obtained pertinent documents, and conducted interviews. Substantiated This agency has investigated the allegation that facility staff are not properly trained. LPAs De Perio and Alejandre reviewed 4 staff files, of which only 1 included the required staff training, while the remaining 3 files for 3 staff members did not have the required 20-hours of annual staff training. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. This agency has investigation the allegation that facility staff are not background checked and associated to facility. Based on LPAs observations and interviews which were conducted and record review, one out of the two staff present at facility for this visit did not complete a background check, nor receive clearance. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Civil penalty assessed and issued. For today's visit a civil penalty and citations were issued per Title 22 Division 6 of the California Code of Regulations. See LIC9099-D and LIC421BG. LPAs De Perio and Alejandre also provided AD Martires information regarding the Guardian system. LPAs De Perio and Alejandre conducted an exit interview with AD Martires and a copy of this report, citations, civil penalty, and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, Nov 22, 2022 · control 22-AS-20221117092305

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Nov 22, 2022

1569.625(b)(2) Staff training; legislative findings; contents (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually... This requirement is not met as evidenced by: Based on observation, record reviews and interviews, facility did not ensure that 3 out of the 4 staff files reviewed, had the required 20-hours of annual training, which poses an immediate health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2022

Plan of correction: As plan of correction (POC), administrator will submit proof of completed required staff trainings to CCL and assigned LPA on or by 11/23/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87335(b) · Plan of correction due date: Nov 22, 2022

87355 Criminal Record Clearance (b)...any adults other than a client, residing in the facility shall have criminal record clearance or exemption. This requirement is not met as evidenced by: Based on observation, record reviews, and interviews, facility did not comply with the section cited above as LPAs observed no clearance for one of the staff present at the facility, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2022

Plan of correction: As plan of correction (POC) administrator will ensure that all staff members and volunteers in the facility will receive clearance prior to working in the facility, and will submit proof to CCL and assigned LPA on or by 11/23/22.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Administrator Aida Martires and explained the reason for the visit. LPA Frank toured the facility. There are 5 residents residing in the facility and no active COVID-19 cases. LPA observed 5 residents on site. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. Facility is taking residents temperatures and documenting results. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan. In addition, LPA Frank tested the hot water temperature, which measured 110.1 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The facility also has fire extinguisher that was mounted and charged. LPA Frank confirmed food supply: 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet. LPA observe the facility to be clean and in good repair. LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808) Mitigation Plan and 3) Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500); Based on the observations made during today’s visit, no deficiencies are being cited in area inspected. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, May 25, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by Caregivers Ofelia Santos and David Tagalicud. LPA advised Caregivers the reason for the visit. Administrator Aida Marites arrived shortly after and reason for visit was shared. Upon entry LPA was screen per COVID guidelines. LPA began the tour of the facility. The facility currently has 4 residents in care. LPA observed 2 residents in the living room relaxing, and 2 residents asleep in their bedroom, All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to COVID for all the visitors, staff, and resident. LPA observed hand washing guidelines posted in all bathrooms of facility. LPA observed facility has COVID precautionary posting throughout the facility as well as all required Department postings. Facility has an active COVID-19 prevention plan in place for the safety of residents in care. LPA observed ample of emergency food and water as well as First Aid kit in the facility. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place. LPA observed caregivers cleaning and sanitizing facility. LPA toured the outside and observed 2 shaded outside space for resident, area can be used for outdoor visitation as well. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation as needed. Facility has 4 private bedrooms, 2 shared bedrooms, and 1 staff bedroom. During the walk through, LPA observed the Sunroom is being converted into a kitchen. LPA obtained a copy of Mitigation Plan. Based on the observations made during today’s visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this report was provided and left at facility.the state’s words, verbatim · CDSS document, Jul 22, 2021

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.