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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 11/10/2022
Date Signed: 11/10/2022 01:32:52 PM


Document Has Been Signed on 11/10/2022 01:32 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:AUDREANNA VERLINGFACILITY TYPE:
740
ADDRESS:14789 BURNS VALLEY ROADTELEPHONE:
(707) 995-1900
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY:56CENSUS: 49DATE:
11/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Audreanna Verling - AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility for the purpose of following up on an incident report received in the Regional Office (RO). LPA met with Administrator Audre Verling.

LPA was following up on a self reported incident report received on 11/9/2022 regarding resident (R1) who on 11/8/2022 was complaining of abdominal pain and shortness of breath. R1 was admitted to the hospital with pulmonary embolism and diverticulitis. Nothing else was reported.

While at facility Administrator informed LPA R1's family member informed facility R1 will probably be returning to facility 11/11/22 with new medications. Facility will update required records.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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