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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:26:16 PM


Document Has Been Signed on 01/09/2024 03:26 PM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ORCHARD PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
176803831
ADMINISTRATOR:AUDREANNA VERLINGFACILITY TYPE:
740
ADDRESS:14789 BURNS VALLEY ROADTELEPHONE:
(707) 995-1900
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:56CENSUS: 43DATE:
01/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Audreanna Verling, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Health and Safety inspection and met with Administrator, Audreanna Verling. The facility has 43 residents in care.

Upon arrival, LPA observed facility to be clean and at a comfortable temperature, plentiful food, and adequate staffing, with all utilities working. There are 28 assisted living residents and 15 memory care residents. No Health and Safety Risks were observed during today’s visit.

There were no deficiencies cited during today’s visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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