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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:38:38 AM


Document Has Been Signed on 05/20/2022 11:38 AM - 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:
05/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Audreanna Verling TIME COMPLETED:
11:39 AM
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On 5/20/2022 Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator Audreanna Verling.

LPA arrived at 9:00 AM at facility to follow up on a self-reported incident report (SIR) submitted to department on 5/17/2022. The SIR informing R1 left facility on 5/15/2022 with a person that is not authorized to take R1 from the facility. On 2/2022 R1 moved into facility.

LPA conducted interviews and reviewed records. Record review revealed R1 has a Power of Attorney (POA), R1 does not have a dementia diagnosis. Facility was unable to provide legal document restricting R1 from any visitors.

LPA conducted interview with R1 and discussed outside visitors.

LPA and Administrator have discussed regulation and has given a technical assistance for regulation 87458(b)(1) as medical report was not fully completed.

At approximately 9:30 AM LPA observed R1’s “ability to leave facility unassisted was not stated” on their Physician Report (form LIC 602). LPA observed Administrator preparing LIC 602 forms for Physician visit for R1 that was made while LPA was still at facility.


No citations issued during today's visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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