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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804112
Report Date: 05/07/2024
Date Signed: 05/07/2024 05:18:04 PM


Document Has Been Signed on 05/07/2024 05:18 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eric Perry-AdministratorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Alviso conducted Required - 1 Year inspection, on 5/7/24 at approximately 12:00pm, and met with Administrator Eric Perry. LPA toured the facility, including the memory care unit.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for twenty (20) residents. Fire clearance is approved for ninety-two (92) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Facility has a supplies to meet the seventy-two (72) hour shelter in place requirements.

Every stairwell, four (4), had a required evacuation chair, with posted instructions on use. All common areas, observed bathrooms, and resident units had sufficient lighting as required. LPA observed meal service throughout the inspection for resident scheduled mealtimes. The food supply was sufficient. The kitchen was observed to be clean and orderly. All medications were locked and inaccessible to residents in care. The facility had all observed exits unobstructed. All fire extinguishers, eighteen (18), were serviced and tagged, 1/25/24, as required. First aid kits were observed to have all required items. Hot water was checked at 112. degrees Fahrenheit and 113.4 degrees Fahrenheit.

The Department will continue this annual inspection at a later date.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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