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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803920
Report Date: 08/17/2020
Date Signed: 08/26/2020 04:08:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ORCHARD INNFACILITY NUMBER:
496803920
ADMINISTRATOR:FLETCHER, SOPHIE ANNAFACILITY TYPE:
740
ADDRESS:2228 SYCAMORE AVETELEPHONE:
(972) 983-3008
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:6CENSUS: 5DATE:
08/17/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Applicant, Sophie FletcherTIME COMPLETED:
11:00 AM
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Licensing Program Analyst Willis conducted the prelicensing inspection via video conferencing due to Covid 19 precautions. LPA met with Applicant, Sophie Fletcher and current Manager, Amanda Mitchell.

Applicant has applied for a Change of Ownership for this already existing facility. Facility has six bedrooms allowing for single occupancy of each room. Facility received an approved fire clearance June 17, 2020 that allows for six non-ambulatory residents. Manager conducted a walk through via video conferencing and LPA observed that resident rooms were furnished per regulations and bathrooms were equipped with nonskid mats and hand rails for safety. Exterior doors have functioning alarms. Facility has required postings including but not limited to the CCL Complaint Poster, Resident Bill of Rights and Resident Rights to Resident Councils. Facility has adequate dishes and cooking materials to provide meals to residents. Facility has at least two days of perishable and one week of nonperishable foods. Facility has space indoors and outdoors for resident activities. Disinfectants are locked in a cabinet under the kitchen sink.

Applicant tested water in the kitchen during inspection. LPA observed that water temperature read at 113.0 degrees F which is within the range allowable per regulation.

Resident and staff records are maintained and stored in a locked cabinet to ensure privacy. Medication is centrally stored and locked in a cabinet. A Centrally Stored Medication Log is maintained.

LPA discussed facility's Disaster Preparedness with Applicant including observing their Emergency Supplies and provisions for transporting medication. Applicant showed LPA the contents of their First Aid Kit.

Component III is waived due to Applicant being a current RCFE Licensee.

LPA will provide this report to the Centralized Application Unit to continue application process.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020
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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