496804112-6-20-2024-21-AS-BMOS-D7EM2S-20240722091401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 06/20/2024
Date Signed: 06/20/2024 05:34:23 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
04/30/2024 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240430151506

FACILITY NAME:	LODGE AT PINER ROAD, THE		FACILITY NUMBER:	496804112
ADMINISTRATOR:	PERRY, ERIC		FACILITY TYPE:	740
ADDRESS:	1980 PINER ROAD		TELEPHONE:	(707) 852-2234
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	92	CENSUS: 62	DATE:	06/20/2024
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Eric Perry-Administrator		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Staff neglect resulted in a resident being hospitalized
Staff neglect resulted in a resident sustaining a fracture while in care

INVESTIGATION FINDINGS:

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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 "staff neglect resulted in a resident being hospitalized, and
staff neglect resulted in a resident sustaining a fracture while in care."

LPA reviewed records on resident, R1, conducted interviews with staff, and other related parties. The investigation revealed that R1 has a care plan in place; Care services are provided for incontinent care, frequent checks on the resident, a minimum of four (4) times every shift. R1 had an unwitnessed fall on 1/30/24 in their bedroom; Staff assessed and contacted 911 for emergency assistance for R1. R1 was hospitalized due to sustaining a fracture, and neededing surgery. R1 was admitted into skilled nursing care on 2/1/24, and discharged back to the facility on 4/12/24. Facility updated care plan to meet R1's current needs.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (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)

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Control Number 21-AS-20240430151506

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

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Continued from LIC9099...

Per review of records, including facility and medical documentation, no information documented neglect/abuse regarding the incident of R1 on 1/30/24. R1 is not a one to one care resident, and at the time of the fall didn't need one to one care. Currently the resident has physical therapy, and a companion two to three times a week for a few hours to help with exercising. In review of allegations, information obtained, interviews with staff, and other related parties, there was no information obtained that supported that a violation had occurred, regarding the allegations.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "staff neglect resulted in a resident being hospitalized, and staff neglect resulted in a resident sustaining a fracture while in care." 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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (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)

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