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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176803831
Report Date: 10/30/2023
Date Signed: 10/30/2023 01:28:02 PM


Document Has Been Signed on 10/30/2023 01:28 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: 43DATE:
10/30/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Audreanna Verling, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst Hansen arrived unannounced to conduct a Health and Safety inspection and met with Administrator, Audreanna Verling. The facility has 43 residents in care.

Upon arrival, facility was clean and at a comfortable temperature. Kitchen staff was cleaning kitchen and appeared to be preparing lunch. LPA observed 2 days of fresh and 7 days of nonperishable foods available for residents in care, following Title 22 Regulations. LPA noted that utilities were on and functioning. There are 28 assisted living residents and 15 memory care residents. Facility has 2 caregivers in assisted living on AM and PM shifts, and same for memory care, who also has a resident care coordinator and a med tech covering each shift for the whole facility. Facility has 2 caregivers on NOC shift in memory care and 2 in assisted living with 1 floater and a med tech for the facility.

Facility emergency generator is half filled and will fill on 11/1/2023 with p-care.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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