496804112-5-11-2023-21-AS-DALO-CRQRCM-20230511125436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804112
Report Date: 05/11/2023
Date Signed: 05/11/2023 12:54:43 PM

Document Has Been Signed on 05/11/2023 12:54 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:	LODGE AT PINER ROAD, THE		FACILITY NUMBER:	496804112
ADMINISTRATOR:	REYES, ALANA		FACILITY TYPE:	740
ADDRESS:	1980 PINER ROAD		TELEPHONE:	(707) 592-1157
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	92	CENSUS: 0	DATE:	05/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jason Reyes & Alana Reyes-CM LLC		TIME COMPLETED:	01:00 PM

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	Licensing Program Analyst(LPA) conducted a prelicensing inspection, on 5/11/23 at approximately 9:30am, and met with Jason Reyes Calson Management, LLC(CM LLC), Principal, Alana Reyes of CM LLC Regional Manager, and hired Administrator Lisa DiBartolo. LPA will be touring the facility with the above named Administration staff. The requested capacity is ninety-two(92) residents; The facility will be providing assisted living needs, and memory care needs. The fire clearance approval dated 4/21/2023, clears the facility for a total of ninety-two(92), seventy-two(72) non-ambulatory and twenty(20)bedridden. LPA observed when entering the facility a large sitting area to the right, with a small cafe area, with an ice cream shop, and to the left a large facility reception area for staff. The first floor is all assisted living, and the second floor is assisted living, which also houses a memory care unit. The facility's capacity breakdown of ninety-two(92) is, sixty-six(66) in assisted living and twenty-six(26) in memory care. Hot water was checked at 113F, which is within regulation. The memory care has a keypad for entry into the memory unit, through a delayed egress door. There are office rooms for the memory care staff. All stairwells, total of three(3), had the required evacuation chairs, with instructions posted on how to use the chair. All exits were observed to be clear and unobstructed. A sample of fire extinguishers were checked and found to be serviced and tagged as required, expires 12/22/23; A total of eighteen(18) fire extinguishers, eleven(11) on the first floor, and seven(7) on the second floor. There is a locked medication room on the first floor and a locked medication room in memory care, for centrally storing all medications. There are cabinets and storage rooms for locking cleaners, and toxins as required. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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

FACILITY NAME: LODGE AT PINER ROAD, THE	FACILITY NUMBER: 496804112
	VISIT DATE: 05/11/2023

NARRATIVE

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LPA observed the facility to have a required emergency food and water supply. The facility has a large kitchen on the first floor, all appliances, stoves/ranges/grills, refrigerators, and freezers, were all in place. and working properly during the inspection. Sufficient supply of furnishings were observed throughout the facility for resident use in both assisted living areas, and memory care unit. There was sufficient lighting observed in the facility in all common areas, hallways, and restrooms. Resident units have non-slip mats/flooring in showers, and bathrooms have grab bars for resident use. Resident units have multiple emergency call systems in each unit. There are a couple studio units, majority of rooms are two bedroom units, and one bedroom units available to residents. There is a theater room in assisted living for resident use. There is also a movie room in the memory care unit for residents use. There is a very large dining area for meals, and an also be used for group activities as needed. There is sensory music and lighting in the memory care unit. There is a smaller serving kitchen for meals, drinks, and snacks for residents in the memory care unit. There is a large dining area in assisted living for residents use. There is an outside courtyard patio for resident use in the memory care, which includes patio furnishings. The assisted living area has outside patios for residents use.

The grounds were free of any apparent hazards, and exits were clear. No bodies of water. No firearms.

LPA conducted a component III orientation with Applicants, and the hired Administrator.

Pre-Licensing is complete and this facility has no apparent health hazards and/or concerns observed during this inspection. The LPA will send a copy of the report to the Application Unit Analyst; The Application Unit Analyst will notify the applicant of the status of the application.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC809 (FAS) - (06/04)

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