496804112-12-6-2023-21-AS-VBEI-CYMUMT-20231218144251

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:37:56 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
08/28/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230828094126

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:	12/06/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Eric Perry-Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff mismanaged resident’s medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 9:35am on 12/6/23, and met with Administrator Eric Perry.
LPA reviewed resident records, including medication records, conducted interviews with staff, and other parties. The investigation revealed that resident(R3) didn't receive medications as prescribed by the Physician. Per record reviews, and staff (S1,S2) interviews, resident had a change in medication order on 8/1/23, but the medication continued to be provided to the resident three times a day (3xs a day) per the old order; The new Physician's order was to provide the medication at one pill a day to the resident.

The medication ran out sooner then it should have. The facility purchased the medication and provided the medication to the resident per new order dosage instructions. The resident (R3) received their medication in error, one medication, from 8/1/23 through to 8/21/23.

Continued on LIC9099C...

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: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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 5

Control Number 21-AS-20230828094126

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: 12/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/07/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: LPAs investigation, review of records, and interviews with staff, and other related parties.	1 2 3 4 5 6 7	Submit plan of correction of policy and procedures, of medical records staff, and medication technicians, ensuring all medications are provided to residents as prescribed by the Physician. POC due 12/7/23.
	8 9 10 11 12 13 14	The resident (R3) received their medication in error from 8/1/23 through to 8/21/23. R3's Order had changed on 8/1/23, but the resident received three pills a day instead of the new dosage of one pill a day. This is a risk to residents health and safety. Second/repeat citation within twelve (12) months, a civil penalty (CP) is assessed in the amount of $250 today, see LIC421FC	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: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
08/28/2023 and conducted by Evaluator Dina Alviso

COMPLAINT CONTROL NUMBER: 21-AS-20230828094126

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:	12/06/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Eric Perry-Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff did not seek medical attention for the resident.
Staff does not keep care records and/or medical records on resident(s)
Staff are not providing incontinet care in a timely manner, and leaving residents in soiled diapers
Staff do not meet residents’ hygiene needs in a timely manner
Staff not providing residents with meal(s) in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 9:35am on 12/6/23, and met with Administrator Eric Perry.

LPA reviewed resident records, food service plan, medication records, medical records, incidents, and observed some resident meal times during inspections, LPA conducted interviews with staff, and other related parties regarding the investigation.

The investigation revealed that shower schedules are set up for all residents, and staff are assigned to meet residents care needs, including showers/hygiene care, incontinent care needs, and staff to assist residents with prescribed medications. Podiatry nail care is done by a Podiatry doctor and/or a medical professional; Residents see thier Physicians for this service, set up by responsible party and/or the facility staff. There are care plans and medical records, including medication records on residents. There has been some mix-up on some resident documentation, and medication order records, but during the investigation LPA observed resident records requested were provided during this investigation. The facility does provide incontinent care per care plan reviews and staff interviews.

Unsubstantiated

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: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20230828094126

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
	VISIT DATE: 12/06/2023

NARRATIVE

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R1 had a catheter that theyhad issues with, and the Physician discontinued the need for R1 to have the catheter, per interviews with S1 & S2. R1 was receiving in-home health services at the time. It is unknown per investigation, if there was any other time resident had catheter issues. Meals were observed by the LPA to be served at scheduled meal/ food service times per facility plan during LPA inspections; It is unknown if there are other times that meals are not being provided timely to residents in care. There was differing information obtained regarding allegations from what was reported to the Department. No information obtained to support that the violations occurred.

Based on the interviews with staff, and other related parties, record/document reviews, and information obtained during the investigation, the allegations, "Staff did not seek medical attention for the resident,
Staff does not keep care records and/or medical records on resident(s), Staff are not providing incontinent care in a timely manner, and leaving residents in soiled diapers, Staff do not meet residents’ hygiene needs in a timely manner, Staff not providing residents with meal(s) in a timely manner " are Unsubstantiated, meaning that although the allegations 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 the Administrator Eric Perry.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20230828094126

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
	VISIT DATE: 12/06/2023

NARRATIVE

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Based on LPA interviews, review of records, and information LPA obtained, the investigation has revealed that the allegation of "staff mismanaged resident’s medication." 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.

Second/repeat citation within twelve (12) months, a civil penalty (CP) is assessed in the amount of $250 today, see LIC421FC.

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 Administrator.
Appeal rights provided.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

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