176803831-9-15-2021-21-AS-SHAN-C6VSVW-20210915141324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:13:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	VONWAL, JEFF		FACILITY TYPE:	740
ADDRESS:	14789 BURNS VALLEY ROAD		TELEPHONE:	(541) 840-4035
CITY:	CLEARLAKE	STATE: CA	ZIP CODE:	95422
CAPACITY:	56	CENSUS: 40	DATE:	09/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Jodie Niezgoda LVN & ED AudreAnna Verling		TIME COMPLETED:	02:10 PM

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	Licensing Program Analysts (LPA) Shannan Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by Jodie Niezgoda LVN. There were 40 residents present at the facility of a max capacity of 56 and 2 on hospice with a waiver for 5. Executive Director AudreAnna Verling attended part of the annual via phone and had Measha Edwards sign for her. On 9/15/2021 at 10:40am LPA arrived at the facility and had her temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. LPA toured the facility with Jodie Niezgoda LVN. During tour facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, and storage areas were inspected. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezer were clean, and food was stored properly. Fire Extinguishers were found to be last charged on 7/8/2021 at the time of the visit. Smoke detectors were tested and found to be in working order. Facility has fire sprinklers throughout. Carbon Monoxide detector was present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure, in med room. Hot water temperature measured 116.9 degrees F, 118.5, degrees F and, 119.3 degrees F within acceptable regulations of 105 to 120 degrees F in 3 of 3 client’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. Toxins are stored in a locked housekeeping closet in the hallway. All resident’s bedrooms have lighting & appropriate furnishings. Continue LIC 809-C .

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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, 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: 09/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with Licensee & LVN, the facility did not ensure that all staff have current 1st aid. LPA learned that 2 of 4 staff (S1) & (S2), does not have proof of current first aid certification which poses a potential health & safety risk to residents in care.
	POC Due Date: 09/24/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1 & S2 to CCL by POC date of 9/24/2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ORCHARD PARK SENIOR LIVING COMMUNITY	FACILITY NUMBER: 176803831
	VISIT DATE: 09/15/2021

NARRATIVE

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Infection Control:

Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility. Facility has PPE supply stored in the office, laundry room, and shed. Facility has a 30-day supply of medication for residents. Staff had all PPE training required on file as well have been N95 Fit Tested. LPA discussed with ED Verling & LVN Niezgoda of current requirements that all visitors must either have a copy or tracking information of vaccine or negative COVID test results from the last 72 hrs prior to visiting.

In addition, facility has a designated area for visitors outside which are being allowed for scheduled visits. Residents also have available zoom, facetime, and telephone calls when contacting with family members and others. Disaster Drills are conducted quarterly with the last being May 2021.

LPA advised facility to contact Lake County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

S1 & S2 do not have current required 1st Aid training

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

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