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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 176803831
Report Date: 12/15/2025
Date Signed: 12/15/2025 03:37:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
11/19/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20251119145338
FACILITY NAME:ORCHARD PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
176803831
ADMINISTRATOR:JONES, MELISSAFACILITY TYPE:
740
ADDRESS:14789 BURNS VALLEY ROADTELEPHONE:
(707) 995-1900
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:56CENSUS: 26DATE:
12/15/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Melissa Jones, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not respond to resident council in a timely manner
INVESTIGATION FINDINGS:
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On 12/15/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20251119145338 investigation findings regarding the above allegation and met with Melissa Jones, Administrator. Reporting Party (RP) alleges that staff did not respond to resident council in a timely manner.

On 11/20/2025, LPA Florio conducted a phone interview with RP and requested copies of correspondence regarding recent resident council meeting notes. On 11/21/2025, LPA received copies of these documents for 02/14/2025, 09/12/2025, and 11/14/2025 resident council meetings. Based on the interview conducted and documents received, it was revealed that the 02/14/2025 and 09/12/2025 meeting minutes were not signed by the resident council president or the facility administrator as required.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
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-20251119145338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ORCHARD PARK SENIOR LIVING COMMUNITY
FACILITY NUMBER: 176803831
VISIT DATE: 12/15/2025
NARRATIVE
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Continued from LIC9099...

On 11/25/2025, LPA conducted 10-day complaint investigation visit and obtained documents, made observations, and conducted interviews. Based on resident council meeting notes received during this visit, the 05/09/2025 meeting notes were signed by the administrator on 06/12/2025 which is beyond the required 14-day response time frame and the notes were not signed by the resident council president as required. Additionally, for the 06/13/2025 meeting, the administrator did not sign the meeting notes until 07/09/2025 which is outside the required response time frame and again did not ensure the president reviewed and signed the notes.

Based on observations made, interviews conducted and records obtained, the allegation that staff did not respond to resident council in a timely manner is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Health and Safety Code, (see LIC9099D).

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20251119145338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 12/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2025
Section Cited
HSC
1569.157(c)
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Resident-oriented facility council 1569.157(c) If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days.
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Licensee agrees to submit a seflf-certificaton that they have reviewed and understand Health and Safety Code section 1569.157(c) as it pertains to the required 14 day response time frame to the resident council to CCLD by POC due date 12/29/2025.
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This requirement is not met as evidenced by:
Based on records reviewed and interviews conducted, Licensee did not ensure they responded to the resident council in a timely manner as required. This poses a potential Health, Safety and/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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
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