176803831-9-15-2022-21-AS-SHAN-CJATJV-20220915144659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:47:10 PM

Document Has Been Signed on 09/15/2022 02:47 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:	AUDREANNA VERLING		FACILITY TYPE:	740
ADDRESS:	14789 BURNS VALLEY ROAD		TELEPHONE:	(707) 995-1900
CITY:	CLEARLAKE	STATE: CA	ZIP CODE:	95422
CAPACITY:	56	CENSUS: 40	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Jodie Niezgoda, Resident Care Director		TIME COMPLETED:	02:50 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	Licensing Program Analysts (LPA) Shannan Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by Resident Care Director, Jodie Niezgoda LVN. There were 40 residents present at the facility, 1 on hospice with a waiver for 5 and 10 in memory care. Administrator AudreAnna Verling was out and unable to attended. Resident Care Director(RCD), Jodie Niezgoda, designee, conducted annual with LPA today. On 9/15/2022 at 11:10am LPA arrived at the facility and had her temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. LPA toured the facility with Jodie Niezgoda, RCD. During tour, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, and storage areas were inspected. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezer were clean, and food was stored properly. Fire Extinguishers were found to be last charged on 8/14/2022 at the time of the visit. Smoke detectors were tested and found to be in working order. Facility has an automatic sprinkler system that was last inspected 3/14/2022. Carbon Monoxide detector was present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure, in medication room. Hot water temperature measured 114.4 degrees F, 117.5, degrees F and, 118.2 degrees F within acceptable regulations of 105 to 120 degrees F in 3 of 3 client’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. Toxins are stored in a locked housekeeping closet in the hallway. All resident’s bedrooms have lighting & appropriate furnishings. Disaster Drills are conducted quarterly with the last being a fire drill 8/31/2022. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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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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: 09/15/2022

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Infection Control:

Facility has submitted a mitigation program plan that has been approved along with Infection Control Plan. Posters have been placed at facility. Front entrance staff check temperatures and log and offer hand sanitizer to visitors and staff. Facility has PPE supply stored in spa room and shed. Facility has a 30-day supply of medication for residents. All staff had masks on during this visit.

LPA Hansen reviewed Licensing Information System (LIS) with RCD Jodie Niezgoda who stated that it is correct and updated at this time. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

In addition, facility has a designated area for visitors in the courtyard, private dinning room, and in bedrooms. Residents also have available Facetime, Zoom, and telephone calls for visits. Residence have physical exercise classes and mental, along with Wii Sports, a guarding club, and available spa.

Staff had all PPE training required on file and have obtained N-95 fit testing.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.

Administrator Certificate is for Audreanna K Verling #6059800740 Exp. 6/9/2023
All staff who do not have waivers have received COVID booster vaccinations.

No deficiencies cited during todays inspection

LPA Hansen is requesting Administrator to update and submit the following documents by 9/30/2022:

LIC 308 Designated

LIC 309 Administrative Organization

Articles of Corporation

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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