496804112-12-8-2025-21-AS-BMOS-DRKPRH-20260223103245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 12/08/2025
Date Signed: 12/08/2025 06:35:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20251007150201

FACILITY NAME:	IVY PARK AT PINER		FACILITY NUMBER:	496804112
ADMINISTRATOR:	PERRY, ERIC		FACILITY TYPE:	740
ADDRESS:	1980 PINER ROAD		TELEPHONE:	(707) 852-2234
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	92	CENSUS:	DATE:	12/08/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Eric Perry-Administrator		TIME COMPLETED:	06:35 PM

ALLEGATION(S):

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Facility staff did not ensure resident needs were being met
Facility staff did not ensure resident was provided access to call button

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 10:45am on 12/8/2025, and met with Eric Perry, Administrator, and Dori Elder, Resident Care Coordinator.

Reporting party (RP) alleges that "facility staff did not ensure resident needs were being met" and "facility staff did not ensure resident was provided access to call button." LPA reviewed resident R1's records, including admission records, medical assessment, care plan, and medications/Dr's Orders. LPA toured the facility. LPA requested copies of records; LPA was provided the requested copies during the inspection. LPA conducted interviews with staff, and other related parties.

The investigation revealed that R1 had been declining slowly, and was being seen on 10/4/25 in the hospital for a rash; R1 returned to the facility on 10/4/25 with no discharge paperwork. Facility was unaware on 10/4/25 that while hospitalized, R1 had been accepted for hospice care by Providence Campusses. Hospice agency nurse came out to see R1 on10/5/25, but there was no hospice care plan left and/or faxed to the facility Administrator and/or other administration staff of the facility.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20251007150201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: IVY PARK AT PINER	FACILITY NUMBER: 496804112
	VISIT DATE: 12/08/2025

NARRATIVE

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. The facility had their care plan in place only during this time for R1's care. Facility became aware of hospice care for R1 on 10/5/25. The facility had been requesting a copy of the hospice care plan from the agency, since it was not provided the day of R1's acceptance on 10/4/25 and/or on 10/5/25 when R1 was seen by hospice agency Nurse at the facility. The care plan was received by the facility late pm, approximately 8pm, on 10/6/25.

On 10/7/25, Administrator and Resident Care Coordinator were reviewing care plan, instituting care plan for R1, and discussing with hospice staff R1's medications due to R1's not having the ability to take some of their medications. Per interviews, R1 was receiving food, drinks/liquids, and care upon the return of R1 to the facility. Per LPA's tour of R1's room the resident had a call button in their room, it is unknown if there was a call button previously. Per staff interviews, R1 was refusing care assistance, and was very agitated upon their return; R1 was monitored by staff, and provided needed services as resident allowed/and let care staff provide at the time.

On 10/8/25 the hospice agency had agreed to ensure R1 would receive their medication as needed/required for their care, coming out to provide certain medication to R1 while on hospice services. Administrator stated that the hospice agency did come in to provide R1's needed medication until their passing.

There was no information obtained that supported a violation occurred regarding the allegation. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "facility staff did not ensure resident needs were being met" and "facility staff did not ensure resident was provided access to call button." are Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited.
Exit interview was conducted with Eric Perry, Administrator.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025

LIC9099 (FAS) - (06/04)

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