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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803920
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:45:00 PM


Document Has Been Signed on 09/15/2022 03:45 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 INNFACILITY NUMBER:
496803920
ADMINISTRATOR:FLETCHER, SOPHIE ANNAFACILITY TYPE:
740
ADDRESS:2228 SYCAMORE AVETELEPHONE:
(972) 983-3008
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:6CENSUS: 4DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Licensee, Donald FletcherTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Donald Fletcher. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by a caregiver. LPA confirmed with Licensee that all visitors are screened and staff are conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 2;40PM and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Staff continue to receive PPE training and have been N95 fit tested. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced July 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.


Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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 2


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 INN
FACILITY NUMBER: 496803920
VISIT DATE: 09/15/2022
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Continued from LIC809

Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee to submit updates of the following documents by 10/15/2022:

LIC 308 Designated Administrator (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Liability Insurance

LPA discussed Reporting Requirements with Licensee and provided a copy of Title 22 Regulation 87211 - Reporting Requirements.

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: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2