496804310-6-5-2025-21-AS-SHAN-DHCPK3-20250605112229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804310
Report Date: 06/05/2025
Date Signed: 06/05/2025 03:12:50 PM

Document Has Been Signed on 06/05/2025 03:12 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:	TAKING THE JOURNEY ORCHARD		FACILITY NUMBER:	496804310
ADMINISTRATOR/ DIRECTOR:	ERIKSEN, KELLY		FACILITY TYPE:	740
ADDRESS:	309 ORCHARD LANE		TELEPHONE:	(707) 338-8812
CITY:	PENNGROVE	STATE: CA	ZIP CODE:	94951
CAPACITY: 6		CENSUS: 6	DATE:	06/05/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:07 AM
MET WITH:	Kelly Eriksen, Licensee/Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/05/2025 Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Post-Licensing Inspection of facility and was welcomed by staff Alberto Lopez. Staff contacted Administrator Kelly Eriksen who arrived during inspection. Facility is a single-story building with 6 bedrooms, and an approved fire clearance for 6 Non-Ambulatory of which 1 may be bedridden. Hospice waver has been granted for 2. There are currently 6 residents with 1 using Hospice services during the time of this inspection. Facility tour/inspection began at 8:10 AM: LPA toured the indoor and outdoor portions of facility on 6/05/2025; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility has special care plan of operation and programming for residents with dementia. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing, as well night lights for residents. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Food is available for residents any time of the day. Cleaning products, sharp items, other toxins and chemicals are kept out of resident access and found secured and stored in the kitchen, laundry room, and shed. There was a supply of cleaners, hygiene products and paper products available for residents. Resident bathrooms had required slip resistant mats and grab bars. Hot water temperature measured between 111.7 degrees F and 115.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathroom faucets. All bathrooms at the facility were supplied with paper towels and hand soap. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TAKING THE JOURNEY ORCHARD	FACILITY NUMBER: 496804310
	VISIT DATE: 06/05/2025

NARRATIVE

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Continued from LIC809

Fire Extinguisher was found to be last charged on 2/12/2025. Smoke detectors and Carbon monoxide detectors were tested and found to be operational. Facility has video surveillance in common areas, that does not include audio.

The back porch of the house has shade and provides a safe and secure area for residents to spend time outside.

File Review began at 9:30 AM:
A review of six residents & sample review of five staff records as well as two resident’s medications was conducted. LPA learned that 6 out of 6 residents have updated reappraisal/needs & care plan as well as medical assessments. Sample review of 5 staff records revealed staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. All direct care staff have received the additional training requirements; LPA was also provided required proof of CPR & 1^st Aid certification.

Medication Audit began at 11:00 AM:
Medications were centrally stored in locked hallway closet/ medication room. LPA observed medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to have all medications entered for residents.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills will be conducted quarterly and in different shifts with the last one being conducted on 4/18/2025. Facility has 1 large generator that can power ¾ of the house in case of power outage. In addition, Kelly Eriksen, Administrator Certificate # 7008387740 expires 11/5/2025.

LPA has requested Licensee to submit Liability Insurance, LIC308 (Designee), & LIC 500 (Personnel Report) to CCL by 6/20/2025.

No deficiencies found. No citations issued.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC809 (FAS) - (06/04)

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