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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 01/24/2023
Date Signed: 01/24/2023 02:01:33 PM


Document Has Been Signed on 01/24/2023 02:01 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: 45DATE:
01/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Audreanna Verling - AdministratorTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator Audreanna Verling.

LPA is following up regarding a self reported Incident Report received on 1/17/2023 regarding resident R1 who on 1/13/2023 at approximately 11:00 PM had an un-witnessed fall, went out and returned. The next day at approximately 4:00 PM R1 was witnessed, excessive sweating, uncontrolled shakes, unable to answer questions and went out. LPA was informed R1 passed away at hospital on 1/15/23. LPA obtained internal documents and requested additional documentation.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
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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