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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803920
Report Date: 09/17/2021
Date Signed: 09/17/2021 10:25:31 AM

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:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff, Gigi Borja, Licensee Keith FletcherTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Staff, Gigi Borja and Licensee Keith Fletcher. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that the facility has a sign on the door notifying visitors that they will be screened. LPA was asked to sign in and temperature was taken and documented. LPA conducted a walk-through of the facility and observed the following: Facility has Covid-19 posters throughout including but not limited to hand washing and cough etiquette. Facility was a comfortable temperature and exits were free from obstructions. Infection control is discussed with residents and staff. Residents receive assistance with hand washing. Residents are encouraged to wear masks when in the community and staff are required to wear them while in the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day.

LPA and staff discussed resident activities and visitation. There is a designated outdoor area for visitation. Visitors may also visit inside of the facility but are required to wear a mask and are screened. Facility to review PIN 21-40-ASC regarding visitation, testing and vaccination verification guidance for visitors. Caregivers have completed PPE training and have been N-95 Fit tested.

Facility has submitted their Covid Mitigation Plan and it has been reviewed. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is located in an area that is accessible to staff who need it. Facility maintains a 30 day supply of medication.


Staff nd LPA discussed their Emergency Disaster Plan.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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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