<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 01/14/2025
Date Signed: 01/14/2025 02:59:02 PM

Substantiated


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
11/05/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241105111834
FACILITY NAME:LODGE AT PINER ROAD, THEFACILITY NUMBER:
496804112
ADMINISTRATOR:PERRY, ERICFACILITY TYPE:
740
ADDRESS:1980 PINER ROADTELEPHONE:
(707) 852-2234
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:92CENSUS: DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eric Perry-AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide resident's medications as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/14/25 at approximately 10:00am, and met with Administrator Eric Perry.

Reporting party alleged that "staff do not provide resident's medications as prescribed". LPA reviewed resident R1 & R2's records, including medication records. LPA obtained copies of requested records, including medication lists, Dr's Orders/signed orders by the Physician, and documentation by staff. LPA interviewed staff, and other related parties.
The investigation revealed that a list of a medication was provided on 10/15/24 by resident's (R1) visiting Nurse, regarding a medication R1 was to be assisted with; The list had no Physician's signature as required, and there was no order prior for this medication from the Physician, per file review. The facility staff stated they needed a Doctor's order, a Physician's signature on the medication list being provided by the Nurse. Facility contacted Kaiser three times and had decided to go to Kaiser and was able to obtain Physician's signature on 10/29/24, per interviews with S1 & S2;The resident had missed the medication for approximately two weeks, due to the facility not having no Dr's Order on file with Doctor's signature.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20241105111834
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: LODGE AT PINER ROAD, THE
FACILITY NUMBER: 496804112
VISIT DATE: 01/14/2025
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
26
27
28
29
30
31
32
Facility contacted Kaiser three times, decided instead to go to Kaiser, and was able to obtain Physician's signature on 10/29/24, per interviews with S1 & S2;The resident had missed the medication for approximately two weeks, due to the facility not having a Dr's Order on file with Doctor's signature.

The investigation revealed that R2 moved into the facility approximately early evening 10/24/24. R2's medication assistance program started on 10/25/24, per record reviews, and staff interviews. R2's medication was ordered in a timely manner but not picked up in a timely manner. Per interviews the resident's refill medications were to be delivered by the R2's representative party. Per interviews, the Administrator picked up the medications from Kaiser, and paid the cost for the medication after being notified by staff the medication hadn't been provided to R2. Per record reviews the medication was missed from 11/7 through 11/14 due to the medication refill not having been picked up.

Per facility Administrator, the admission agreement has a statement regarding medication emergencies "The care facility, as required by law, must obtain medications for the resident/patient timely. If I am unable to supply medications for the above resident I agree to pay Consonus Pharmacy Services for the cost of the medication plus an emergency service fee." Administrator stated that the facility Resident Care Coordinator should have used this, agreed to by signature of representative, to obtain the resident's medication so the medication could have been obtained sooner.

There was sufficient information obtained to support that alleged violation had occurred. Medication was not provided to the resident as required and prescribed by the Physician; The resident's refill medication was not picked up in a timely manner, per investigation, record reviews, and interviews. The reported allegation of "staff do not provide resident's medications as prescribed" is substantiated. This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with the Administrator Eric Perry.
Appeal Rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241105111834
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: LODGE AT PINER ROAD, THE
FACILITY NUMBER: 496804112
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2025
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465(a)(4) Incidental Medical & Dental Care -The licensee shall assist residents with self-administered medications as needed, This requirement was not met as evidenced by: The resident's refill medication was not picked up in a timely manner, per investigation, record reviews, and interviews. This is a risk to resident's health & safety.
1
2
3
4
5
6
7
Licensee to ensure all resident medications are refilled and picked up and/or delivered in a timely manner for all residents in care. Hold an in-service training with all medication staff, including resident care coordinator, and memory care director regarding
8
9
10
11
12
13
14
8
9
10
11
12
13
14
 "assisting residents with medications, ordering refills as required, facility's medication policy/procedures". Submit proof of training by 1/27/25. Plan of correction due 1/15/25.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3