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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 176803831
Report Date: 03/12/2021
Date Signed: 03/15/2021 11:30:00 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2020 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20201204134845
FACILITY NAME:ORCHARD PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
176803831
ADMINISTRATOR:VONWAL, JEFFFACILITY TYPE:
740
ADDRESS:14789 BURNS VALLEY ROADTELEPHONE:
(541) 840-4035
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:56CENSUS: DATE:
03/12/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:AudreAnna VerlingTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is billing resident for an amount that exceeds the SSI rate
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 10:40AM, Licensing Program Analyst (LPA) Chris Arnhold contacted Audreanna Verling to deliver investigation findings for the above allegation. This visit is being conducted via telephone due to Covid-19 precautions. A current facility resident became eligible for Supplemental Security Income (SSI) in August 2020 and notified facility. Per regulation 87464(e), If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. On 12/03/2020, facility Administrator contacted LPA for clarification regarding acceptance of SSI rate when a facility does not accept SSI residents. LPA provided regulation 87464 to Administrator and sent request for clarification to CCLD management. Resident has been paying the SSI rate since August 2020 and facility has accepted the rate but has issued amount due notices to resident, requesting the remaining balance, in violation of regulation.
Continued on LIC9099-C...(Original signature on file)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20201204134845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: ORCHARD PARK SENIOR LIVING COMMUNITY
FACILITY NUMBER: 176803831
VISIT DATE: 03/12/2021
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
Based on LPA’s observations, interviews conducted and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Original Signature on File.



This report was reviewed with AudreAnna Verling and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20201204134845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ORCHARD PARK SENIOR LIVING COMMUNITY
FACILITY NUMBER: 176803831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2021
Section Cited
CCR
87464(e)
1
2
3
4
5
6
7
87464 Basic Services(e)If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This
1
2
3
4
5
6
7
Licensee to follow regulation on SSI rate. Licensee to adjust past due amount to the August 2020 date when resident became an SSI recipient and submit an updated billing statement reflecting the SSI
8
9
10
11
12
13
14
requirement is not met as evidenced by: based on record review, Licensee did not follow regulation and charged full rate for services. This poses a potential risk for residents in care.
8
9
10
11
12
13
14
amount. Billing invoice to be submitted to CCL by POC date of 04/02/2021.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3