176803831-9-12-2024-21-AS-SHAN-D92TGJ-20240912144312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:52:55 PM

Document Has Been Signed on 09/12/2024 04:52 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 COMMUNITY		FACILITY NUMBER:	176803831
ADMINISTRATOR:	DANELLE SANTONI		FACILITY TYPE:	740
ADDRESS:	14789 BURNS VALLEY ROAD		TELEPHONE:	(707) 995-1900
CITY:	CLEARLAKE	STATE: CA	ZIP CODE:	95422
CAPACITY:	56	CENSUS: 35	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Danelle Santoni, Administrator & Melissa Jones, Interim Administrator		TIME COMPLETED:	02:30 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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1 – year inspection visit of the facility. LPA met with Interim Administrator, Melissa Jones. There is a total of 35 residents, 9 of which have dementia diagnosis. There are no residents currently on Hospice. This RCFE has a fire clearance for 56 capacity, 51 non-ambulatory, and 5 bedridden. The facility has a Hospice Waiver approved for 5 residents and a plan of care for dementia residents. At approximately 8:45 AM, LPA toured the building and grounds with Interim Administrator which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in highly visible areas. LPA observed activity room with supplies and daily schedule of six activities posted on activity door and monthly activity calander next to front desk. Facility also has a salon, spa room, private dining room, laundry room and courtyard in middle of building. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly per Title 22 Regulations. Facility has supplies enough to operate for more than 72 hours in an emergency. Toxins are stored in a locked housekeeping closet in the hallway. Water temperature measured between 106.7 degrees F & 116.6 degrees F within regulations of 105 degrees F and 120 degrees F at 9 out of 9 randomly sampled bathroom faucets accessible to residents in care. Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. Resident rooms inspected had sufficient lighting and appropriate furnishing required by Title 22 Regulations. Facility has 16 fire extinguishers which were last inspected on 7/1/2024. Smoke detectors and Carbon Monoxide detectors were tested and found to be in working order. Facility has fire sprinklers throughout that were last inspected by vender 7/2024. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in med room and in 2 locked carts. Continued on LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/12/2024

NARRATIVE

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Continue from LIC809

A review of five staff & five resident records as well as two resident’s medications was conducted. At approximately 11:30 AM, LPA reviewed 5 resident records and found 5 of 5 residents to have current physician's reports, signed admission agreements, care plans and physician's orders on file. Medication records are thorough and contained physician's orders for each resident. LPA interviewed 3 residents during this inspection.

At approximately 12:30 AM, LPA reviewed 5 staff records and found 5 of 5 files for staff requiring current CPR training was observed and completed training records as required including course details and hours of completion provided, although 2 of 5 new staff requiring First Aid did not have current First Aid (see LIC9102-TV) class scheduled. All facility staff present and a sample of others who require caregiver background checks have received criminal record clearances or exemptions. LPA interviewed 3 staff during this inspection.

LPA reviewed Licensing Information System (LIS) with Interim Administrator Melissa who stated that is correct and updated at this time; other than mobile # to be changed. Disaster Drills are conducted quarterly with the last one being conducted on 8/31/2024. Facility has full cite emergency generator. Administrator Certificate for Danelle Santoni # 7028693740 expired 9/1/2024 and is pending renewal. Soon to be new Administrator Melissa Jones Admin Cert. # 6073664740 is also pending.

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 9/30/2024:

LIC 308 Designated (if changes)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Control of Property/Current Lease
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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