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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 06/20/2024
Date Signed: 06/20/2024 05:35:00 PM

Unsubstantiated


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
01/29/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240129113202
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: 62DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Eric Perry-AdministratorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide a comfortable environment for a resident
Facility staff handled a resident(s) in a rough manner
Facility staff did not communicate with a resident, and their family, due to a language barrier
Facility staff did not keep accurate records on a resident
Facility staff mismanaged a resident's medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alviso conducted a complaint investigation, on 6/20/24 at approximately 12:50pm, and met with Administrator Eric Perry.

The reporting party (RP) alleges that "facility staff did not provide a comfortable environment for a resident, facility staff handled a resident (s) in a rough manner, facility staff did not communicate with a resident, and their family, due to a language barrier, facility staff did not keep accurate records on a resident, and facility staff mismanaged a resident's medications."
LPA reviewed records on resident(s), R1 & R2, conducted interviews with staff, and other related parties. The LPA also conducted an interview with Hospice Agency Director of Patient Services, to review case notes on the care and observations by hospice nurses/staff that were coming into the facility regularly to see R2. In review of allegations, interviews, and information obtained, there were no identified/named staff, no exact dates and time able to be provided to the department regarding the allegations.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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 2
Control Number 21-AS-20240129113202
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: 06/20/2024
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
Continued from LIC9099...

The investigation revealed both residents, R1 & R2 were on hospice care. Record reviews and interviews regarding resident care services, medication assistance, incontinent care plan/assistance, including hospice services, had obtained different information than reported to the Department. There was no information obtained to support that violations had occurred regarding the allegations. There was differing information from parties interviewed, and per record review. The interviews conducted with various staff found that staff were able to communicate with the LPA, answer LPA's questions, and speak to the LPA in English; it is not known if before this complaint any staff were not able to communicate clearly. S1 stated that all staff are hired only if they can communicate with all residents, and English is required. Facility's record reviews and interviews obtained no information that staff had not provided a comfortable environment and/or that staff were rough with providing care to R2 or R1 while on hospice/ and in the facility. Records reviewed regarding care services, no information obtained that supported a violation occurred regarding record keeping and/or progress notes reviewed.

The Hospice Agency Director of Patient Services, in summary, stated to the LPA that the hospice staff are very good about documenting notes regarding a resident, care services and/or concerns. In review of R2's case notes there are no concerns regarding care being provided to the resident, no medication concerns, R2 was getting their medications as needed, and there is no documented concerns of any neglect of the resident/R2. Hospice staff would report concerns/neglect of any kind as mandated reporters if observed/suspected. There was no information obtained during the investigation, and interview with hospice agency to support a violation had occurred regarding the allegations.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "facility staff did not provide a comfortable environment for a resident, facility staff handled a resident (s) in a rough manner, facility staff did not communicate with a resident, and their family, due to a language barrier, facility staff did not keep accurate records on a resident, and facility staff mismanaged a resident's medications" 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2