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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804112
Report Date: 08/10/2023
Date Signed: 08/10/2023 05:31:25 PM


Document Has Been Signed on 08/10/2023 05:31 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, THEFACILITY NUMBER:
496804112
ADMINISTRATOR:REYES, ALANAFACILITY TYPE:
740
ADDRESS:1980 PINER ROADTELEPHONE:
(707) 852-2234
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:92CENSUS: 40DATE:
08/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Gladys Finch-Resident Care CoordinatorTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Alviso and Coppo, conducted a Case Management- Incident inspection, and met with Gladys Finch, Resident Care Coordinator(RCC).

This case management is being conducted to cite a deficiency found during the complaint investigation of earlier today, 8/10/23. This deficiency was not related to the complaint.

An incident report on R1 was not completed correctly as it omitted that it was two(2) days, not one(1), of missed PM medications. This deficiency will be cited, 87211(a)(1) Reporting Requirements - each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case, see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, see LIC809D.
Exit interview conducted with the RCC Gladys Finch.
Appeal rights provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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Document Has Been Signed on 08/10/2023 05:31 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2023
Section Cited
CCR
87211(a)(1)

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Reporting Requirements - each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement was not met as evidenced by:
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Licensee/Administrator to ensure all incidents are reported as required; Submit a revised/corrected incident report on the medication error on 7/29 & 7/30, regarding R1. Submit plan of correction and revised/corrected incident report by 8/16/23.
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Per record review, and staff interviews, an incident report on R1 was not completed correctly as it omitted that it was two(2) days, not one(1), of missed PM medications. This is a health and safety risk to resident(s) in care.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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