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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 09/12/2024
Date Signed: 09/12/2024 02:45:29 PM


Document Has Been Signed on 09/12/2024 02:45 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:DANELLE SANTONIFACILITY TYPE:
740
ADDRESS:14789 BURNS VALLEY ROADTELEPHONE:
(707) 995-1900
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:56CENSUS: 35DATE:
09/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Melissa Jones, Interim AdministratorTIME COMPLETED:
03:00 PM
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On 9/12/2024 while conducting Annual Inspection of facility Licensing Program Analyst (LPA) Shannan Hansen conducted a case management.

LPA is following up on a self-reported SIR dated 5/23/24 regarding water temperature. Water temperature during todays’ inspection was in compliance.

No citations cited during todays inspection.

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