176803831-1-30-2024-21-AS-VBEI-CZZTXF-20240131140703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 176803831
Report Date: 01/30/2024
Date Signed: 01/30/2024 01:42:10 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240108085839

FACILITY NAME:	ORCHARD PARK SENIOR LIVING COMMUNITY		FACILITY NUMBER:	176803831
ADMINISTRATOR:	AUDREANNA VERLING		FACILITY TYPE:	740
ADDRESS:	14789 BURNS VALLEY ROAD		TELEPHONE:	(707) 995-1900
CITY:	CLEARLAKE	STATE: CA	ZIP CODE:	95422
CAPACITY:	56	CENSUS:	DATE:	01/30/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Measha Edwards, Assistant Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to lack of supervision, resident was assaulted by another resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Hansen arrived unannounced for the purpose of delivering complaint findings of the above allegation and met with Assistant Administrator Measha Edwards.

Due to lack of supervision, resident was assaulted by another resident- complainant alleges a resident (R1) in the memory care unit of facility has repeatedly assaulted others and although the facility has taken some action, assaults by R1 have escalated significantly putting residents at risk. Investigation revealed R1 was admitted to memory care of facility at the end of June 2023. On 7/15/2023 R1 hit another resident in the back of the head with a coffee cup sending resident to the hospital. Facility removed all glassware from memory care. Record review revealed in August 2023 additional monitoring of R1’s behaviors. Facility records indicate 12/2023 staffing – 3 caregivers for AM shift of facility with 1 Med Tech, same for PM shift.

Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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-20240108085839

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 COMMUNITY	FACILITY NUMBER: 176803831
	VISIT DATE: 01/30/2024

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

Record review and Interview with Administer revealed on 12/4/2023 R1 punched another resident in the face, 12/8/23 physical altercation winding up on the ground with another resident, 12/14/23 medication change On 12/24/2023 Med Tech called to memory care to assist with R1 who was becoming aggressive. R1 punched staff causing concussion & whiplash. On 12/26/2023 facility began 3 day eviction and requested R1’s family to provide 1:1 caregiver which did not start until 12/30/2023. On 12/28/2023 Admin attempted to hire additional staff but due to lack of funding the facility was not able to. Although 1:1 started on 12/30/2023 ; 24/7 in 3 different shifts (7am-3pm, 3pm-11pm, & 11pm-7am), over 7 shifts were not covered due to no shows and facility was unable to fill shift. On 1/10/2024 Community Care Licensing (CCL) received a self reported SOC 341 indicating on 1/5/2024 R1 punched another resident in the jaw.

LPA made observations, conducted record reviews and interviews with staff confirming, after multiple altercations a 1 on 1 was implemented and still did not prevent assaults by resident. Therefore, allegation due to lack of supervision, resident was assaulted by another resident is found to be Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of right provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20240108085839

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 COMMUNITY	FACILITY NUMBER: 176803831
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/30/2024 Section Cited HSC 1569.269(a)(5)(6)	1 2 3 4 5 6 7	HSC 1569.269 (a)(5)(6) Enumerated rights...(a) Residents... shall have...rights: (5) To be accorded safe, healthful, & comfortable accommodations...(6) To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers, qualifications & competency to meet their needs. This requirement has not been met by:	1 2 3 4 5 6 7	Administrator informed LPA search to relocate R1 to another facility began mid December, contacting over 300 facilities in and out of state but was not successful until transfer on 1/15/2024. POC cleared at time of visit.
	8 9 10 11 12 13 14	Based on records review, observation and interviews with staff and Administrator, facility did not ensure the health and safety of clients in care by not having proper supervision in place with staff that are sufficient in numbers, with prior knowledge of R1’s aggressive behavior and repeat assaults.	8 9 10 11 12 13 14	POC cleared at time of visit.
	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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3