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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803920
Report Date: 09/30/2024
Date Signed: 09/30/2024 05:02:43 PM

Document Has Been Signed on 09/30/2024 05:02 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ORCHARD INNFACILITY NUMBER:
496803920
ADMINISTRATOR/
DIRECTOR:		FLETCHER, SOPHIE ANNAFACILITY TYPE:
740
ADDRESS:2228 SYCAMORE AVETELEPHONE:
(972) 983-3008
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Marilyn Aingcayon-CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analysts (LPA) Alviso conducted a required 1-year inspection, approximately 2:10pm on 9/30/2024, and met with caregivers Marilyn Alingcayon,and Miguela Hane. Caregiver Marilyn contacted Licensee/Administrator regarding the LPA's arrival. Administrator Donald (Keith) Fletcher would be coming to the facility to meet with the LPA.

Facility has an approved fire clearance for six (6) non-ambulatory residents. Hospice waiver is approved for four (4) residents. Facility has a required infection control plan. Facility has an emergency disaster plan as required.

Most recent facility fire/disaster drill was conducted on 5/4/24. The Licensee is to ensure to meet the requirement of holding emergency disaster drills quarterly, and on each shift, ensuring one of the quarterly drills is an evacuation.

LPA toured the facility with the Administrator Keith, and caregiver Marilyn; The LPA made the following observations: Facility was at a comfortable temperature and passageways and fire exits were clear of obstructions. Resident rooms were furnished per regulation. Water temperature was measured at 111.1 degrees Fahrenheit, which is within regulation.Sufficient supply of hygiene products, personal protective equipment (PPE), cleaners/disinfectants, paper products, linens, and furnishings. Cabinets containing cleaning/disinfecting supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods; Per staff on shift, main food shopping is done on Fridays. Medications were centrally stored and locked as required. Emergency food and water supplies are stored in the garage; Sufficient supplies to meet the 72-hour shelter in place requirements. All bathrooms had required grab bars for resident use. Facility shower had non-slip flooring/mats for resident use as needed. There was sufficient lighting in all resident rooms, bathrooms, hallways, and common areas. Facility was observed to be clean and orderly.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ORCHARD INN
FACILITY NUMBER: 496803920
VISIT DATE: 09/30/2024
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Fire extinguishers were last serviced July 2024. Smoke and Carbon Monoxide detectors were located throughout the facility as required; All smoke detectors and carbon monoxide detector(s) worked appropriately during the inspection.
Four (4) resident files were reviewed. Three (3) staff files were reviewed. All staff have required criminal record clearance. Staff have required First Aid and CPR certificates. Staff have required training. Medications, and medication records were reviewed.

LPA is requesting the following documents be updated and submitted by 10/30/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required-if changes submit to CCL-review & sign off on last page.)
Infection Control Plan (ensure to review and update as needed/required-if changes submit to CCL-review & sign off on last page.)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

The following deficiencies were observed during resident file reviews:
Per LPA record reviews, R1 & R4 lacked annual medical assessments as required by regulation. This deficiency will be cited, Care of Persons with Dementia 87705 (c)(5)-Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Lead Caregiver, Marilyn Alingcayan.
Appeal Rights provided to the caregiver for the Licensee/Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2024 05:02 PM - It Cannot Be Edited


Created By: Dina Alviso On 09/30/2024 at 04:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ORCHARD INN
FACILITY NUMBER: 496803920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia 87705 (c)(5)-Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's resident record reviews, residents R1 & R4, lacked current medical assessment as required by rgulation, the licensee did not comply with the section cited above in [2] out of [4] residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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License/Administrator to ensure that residents obtain annual medical assessments as required per regulation, and with new assessment they reappraised to ensure all current needs are being met. Submit copies of annual assessments obtained for both R1 & R4 by POC due date of 10/30/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
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