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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 176803831
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:58:57 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
02/23/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240223111603
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: 32DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Danelle Santoni, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff not responding to assist in a timely manner
Staff are not properly trained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced for the purpose of delivering complaint findings of the above allegations and met with Danelle Santoni, Administrator.

Staff not responding to assist in a timely manner - Complainant alleges staff do not respond to resident falls or pendants appropriately and have ignored resident (R6) calls multiple times. Former Administrator on separate occasions stated the facility has a 3-5-minute response time to call buttons and if they can't respond they will go over the radio for someone/anyone to respond to the resident making sure it is not an emergency (from complaint 21-AS-20230214104332). Interview with staff (S3) indicated they believed between 5-7 minutes was the response time frame. CISCOR One Source (call bell system) report obtained from 1/29/2024-2/9/2024 for R6 reflect pendent button initiated 166 times with at least 8 response times between 10-15 minutes, at least 18 response times between15-30 minutes, and at least 2 response times using pendent that were more than 30 minutes to respond to. Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 5
Control Number 21-AS-20240223111603
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: 08/01/2024
NARRATIVE
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Continue from LI9099
LPA attempted to contact R6 multiple times but was unable to conduct interview. LPA was informed corporate nurse may submit a revised plan of operations indicating response time to call bells at approximately 10 minutes, although with this time there are still too many responses out of range for this investigation. Based on LPA’s interviews conducted and a review of call log records, the preponderance of evidence standard has been met, therefore the above allegation staff not responding to assist in a timely manner is found to be SUBSTANTIATED.

Staff are not properly trained – Complainant alleges staff (S2) did not receive appropriate training (specifically hands-on shadowing) when onboarded but was put to work. LPA received documentation indicating S2 was hired on 12/27/2023 and last day worked was 2/16/2024. LPA obtained Resident Assistant Orientation & Skills checklist records signed on 2/16/2024 & page 2 was blank which indicates S2 did not have adequate hand on training prior to working. Regulation 87411(d) states: All personnel shall be given on the job training.. as appropriate for the job assigned. Although S2 had been trained for memory care, they would be placed in assisted living occasionally. Interview with former Administrator corroborated S2 had not been provided proper one on one training of the assisted living side prior to having to work in that department. Based on LPA’s interviews and training logs obtained for S2, the preponderance of evidence standard has been met, therefore the above allegation staff are not properly trained 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.

Appeal Rights Given

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. 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 rights provided.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
02/23/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240223111603

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: 32DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Danelle Santoni, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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9
Personal Rights
Staff are not providing resident's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced for the purpose of delivering complaint findings of the above allegation and met with Danelle Santoni, Administrator.

Personal Rights- Complainant alleges staff (S1) was arguing and yelling at multiple residents, one time calling resident (R2) derogatory names. As well as, forces residents to go to bed and turns off television in the common area while residents are watching. During investigation LPA conducted visits on 2/27/2024 & 5/15/2024 and did not observe staff treating or speaking to residents in a rude manner. LPA contacted 8 residents & 3 staff for interviews regarding allegation of having been treated in a rude or aggressive manor or witnessed others being treated this way by care staff and was unable to confirm allegation by any resident or staff. Although R8 & former Administrator indicated S1 is thorough in ensuring procedures and protocols are executed correctly which could be perceived as being stern.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240223111603
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: 08/01/2024
NARRATIVE
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Continued from LIC9099-C

As well, LPA obtained internal investigation of 6 staff, 1 Aid, & 11 residents that corroborated LPA’s interviews. Based on interviews & observations, LPA is unable to prove residents’ personal rights are being violated by Staff arguing & yelling at residents, calling them derogatory names, and or denying them to watch TV in common area, therefore the allegation is UNSUBSTANTIATED.

Staff are not providing resident's medication as prescribed- Complainant alleges on 1/8/2024 staff (S1) had become irritated with a resident (R1) when the resident had been begging for medications. S1 refused to provide medications to the resident and directed S2 to take the resident to their room to sleep without them receiving their medications. Medication pass records obtained for S1 from 1/7/2024 to 1/9/2024 reveal on 1/8/2024 R1 refused 4 of their 6 evening medications and one of their seven morning medications. It was also revealed R1 refused an evening medication on 1/7/2024 & 1/9/2024 as well as a morning medication on 1/7/2024. LPA’s interview with R1 on 2/27/2024 revealed they didn’t recall any time when a staff did not give them or refused to provide them their medications. Subsequently LPA also interviewed S1 & S2 and did not receive additional information to collaborate staff are not providing medications. Interview with S3 informed facilities protocol for medications refused by residents is to try 3 times to provide the mediations and then if the resident still refuse, it is marked in the Medication Administration Records (MARS) that they refused and the physician is notified by fax. Based on interview and records reviewed, LPA is unable to prove or disprove that Staff are not providing resident's medication as prescribed, therefore the allegation is UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240223111603
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: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for (16) or more, sufficient support staff shall be employed to ensure provision of personal assistance and care.. This requirement was not met as evidenced by:
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Administrator to ensure staff training on time management is conducted and submit a copy of policies regarding call system response by POC due date 8/29/2024.
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Based on LPA record review facility has delayed call response for resident (R6) using their pendant. From 1/29/2024-2/9/2024 R6 requested assistance 166 times, and reflects 8 response times between 10-15 minutes, and at least 18 response times between 15-30 minutes, and at least 2 response times that were more than 30 minutes. This poses a potential risk to the Health, Safety and Personal Rights of residents in care.
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If additional time is needed submit email for extension with date perceived to be completed.
Type B
08/15/2024
Section Cited
CCR
87411(d)
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87411 Personnel Requirements (d)All personnel shall be given on the job training.. as appropriate for the job assigned.. This requirement was not met as evidenced by:
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Licensee/Administrator will ensure all staff have all required training. Administrator to provide self certification on how facility will comply with regulation 87411 (d) on the job training in future and submit to CCL by POC due date of 8/15/2024.
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Based on LPA’s record review and interviews indicate S2 was not given sufficient on the job training for caregiving on the AL floor per resident assistant orientation & Skills Checklist which poses a potential health, safety, or personal rights risk to residents in care.
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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) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5