496804112-8-10-2023-21-AS-VBEI-CYN2SR-20231218163930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 08/10/2023
Date Signed: 08/10/2023 05:37:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/09/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230809142110

FACILITY NAME:	LODGE AT PINER ROAD, THE		FACILITY NUMBER:	496804112
ADMINISTRATOR:	REYES, ALANA		FACILITY TYPE:	740
ADDRESS:	1980 PINER ROAD		TELEPHONE:	(707) 852-2234
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	92	CENSUS: 40	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Nichole		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Facility staff are not providing medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs), Alviso and Coppo, conducted a complaint inspection, at approximately 11:35am on 8/10/23, and met with Gladys Finch, Resident Care Coordinator(RCC), and Ruby Cuevas Memory Care Director(MCD).
LPAs reviewed resident records, including care plan, medication records, and admission records. The investigation revealed that resident(R1) didn't receive medications as prescribed on 7/29 and 7/30; Per record reviews, and staff(S1,S2) interviews, two medications were not provided to the resident as prescribed, due to the medications having not been refilled in time. LPA obtained the copies of R1's records regarding the medication error.
Based on LPA interviews, review of records, and information LPA obtained, the investigation has revealed that the allegation of "Facility staff are not providing medication as prescribed." has been substantiated.
Due to the substantiation of the allegation, a citation, will be cited today, 87465(a)(4) Incidental Medical and Dental Care, 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:
Exit interview conducted with the RCC Gladys Finch.
Appeal rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230809142110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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)
Request Denied Type A 08/11/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	(a) 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: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: The investigation revealed that resident(R1) didn't receive medications as prescribed on 7/29 and 7/30; Per record reviews, and	1 2 3 4 5 6 7	Licensee/Administrator to ensure that residents receive all medications as prescribed; Ensure refills are ordered and received in a timely manner. Hold an in-service training with all medication staff regarding medication policy and procedures. Submit proof of training by 8/28/23. Submit plan of correction by 8/11/23.
	8 9 10 11 12 13 14	staff(S1 & S2) interviews, two medications were not provided to the resident as prescribed, due to the medications having not been refilled in time. This is a health and safety risk to resident(s) in care.	8 9 10 11 12 13 14
	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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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