496804280-9-4-2025-21-AS-BMOS-DPLU4W-20251222141545

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804280
Report Date: 09/04/2025
Date Signed: 09/04/2025 04:59:13 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
07/07/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250707084206

FACILITY NAME:	PINE RIDGE TERRACE		FACILITY NUMBER:	496804280
ADMINISTRATOR:	TAPIA, KARINA		FACILITY TYPE:	740
ADDRESS:	300 FOUNTAINGROVE PARKWAY		TELEPHONE:	(707) 566-8600
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	110	CENSUS:	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Karina Tapia-Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff left resident in a soiled diaper for a long period of time
Staff are not ensuring that resident's glucose levels are checked

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/4/25 at approximately 10:00am, and met with Administrator Karina Tapia and Cheyenne Flores LVN, Health Services Director.

Reporting party alleges that "staff left resident in a soiled diaper for a long period of time, and staff are not ensuring that resident's glucose levels are checked".
LPA reviewed resident (R1) records, including medical assessment, appraisal, medication list, Dr's Orders, progress notes/log, and R1's care plan. The LPA conducted interviews with staff, and other related parties regarding the allegations.

Per review of resident records, facility records, and conducted interviews,the Investigation revealed that R1's care plan does address incontinent care, including the needed checks for incontinent care. R1 does have a call alert pendant to use as needed, and R1 does understand how to use this device. There were no specific dates/times provided of R1's incontinent needs not being met that were reported. There was no information obtained that care staff are not providing incontinent checks on R1 as needed.
No sufficient information was obtained to support that a violation occurred.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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-20250707084206

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: PINE RIDGE TERRACE	FACILITY NUMBER: 496804280
	VISIT DATE: 09/04/2025

NARRATIVE

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Per record reviews, and conducted interviews, R1's glucose checks are being done by the Nursing staff as required before each insulin dose time, three (3) times a day, which includes an additional order of insulin that is provided twice (2) a day within the time of the first insulin order above. There is a PRN as needed insulin order, and if needed this would be provided to R1. Insulin is provided on a sliding scale, which means the Nurse must do a glucose check in order to provide the specific needed dosage to R1. Per record review there is no Dr's Order for late night and/or through the night glucose checks. R1 does have a small device on their arm that provides blood sugar levels/readings. Resident is alert and able to use pendant to alert staff as needed. There was no information obtained that care staff are not providing glucose checks as needed for R1. No sufficient information was obtained to support that a violation occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff left resident in a soiled diaper for a long period of time, and staff are not ensuring that resident's glucose levels are checked" are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Administrator Karina Tapia.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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