176803831-9-19-2023-21-AS-SHAN-CVTTWH-20230919150535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 09/19/2023
Date Signed: 09/19/2023 03:05:45 PM

Document Has Been Signed on 09/19/2023 03:05 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: 33	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Jodie Niezgoda, Health Services Director		TIME COMPLETED:	03:15 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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1 – year inspection visit of the facility. LPA met with Resident Care Director (RCD)/ Designee Jodie Niezgoda, Administrator, Audreanna Verling was not available. There is a total of 33 residents, 14 of which have dementia diagnosis. There are 3 residents currently on Hospice. At approximately 9:45 AM, LPA toured the building and grounds with RCD which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use and daily schedule of five activities posted on activity door. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezer were clean, and food was stored properly per Title 22 Regulations. Toxins are stored in a locked housekeeping closet in the hallway. Water temperature measured between106.1 degrees F & 119.8 degrees F within regulations of 105 and 120 degrees F at 9 out of 9 randomly sampled faucets accessible to residents in care. Fire extinguishers inspected were last charged on 7/18/2023. Smoke detectors and Carbon Monoxide detectors were tested and found to be in working order. Facility has fire sprinklers throughout that were last inspected 4/2023. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. A review of five staff & five resident records as well as two resident’s medications was conducted. At approximately 12:30PM, LPA reviewed 5 staff records and found 5 of 5 files for staff requiring current CPR training was observed, and completed training records as required including course details and hours of completion provided, although 3 of 5 new staff did not have current First Aid (see LIC9102-TV) class scheduled. All facility staff present and a sample of others who require caregiver background checks have received criminal record clearances or exemptions. LPA interviewed 5 staff during this inspection. Continued on LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: 09/19/2023

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
26
27
28
29
30
31
32

At approximately 1:30PM, LPA reviewed 5 resident records and found 5 of 5 residents to have current physician's reports, signed admission agreements, care plans and physician's orders on file. Medication records are thorough and contained physician's orders for each resident. LPA interviewed 3 residents during this inspection.

At approximately 12:30PM, LPA reviewed the facility emergency disaster plan with Maintenance Director. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternate meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills quarterly with the last disaster drill being 5/23//2023.

LPA reviewed Licensing Information System (LIS) with RCD Jodie who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills are conducted quarterly with the last one being conducted on 7/12//2023. Facility has just finished installation of full cite emergency generator. Audreanna Verling Administrator Certificate # 6059800740 is pending renewal.

(Continue LIC 809-C)

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/6/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3