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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804280
Report Date: 01/15/2026
Date Signed: 01/15/2026 03:49:43 PM

Document Has Been Signed on 01/15/2026 03:49 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PINE RIDGE TERRACEFACILITY NUMBER:
496804280
ADMINISTRATOR/
DIRECTOR:		TAPIA, KARINAFACILITY TYPE:
740
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 110CENSUS: 99DATE:
01/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Karina Tapia (Administrator)TIME VISIT/
INSPECTION COMPLETED:
04:08 PM
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Licensing Program Analyst (LPA), Cuadra arrived unannounced to conduct a Required -1 Year visit, and met with Administrator Karina Tapia. Facility has an approved dementia care plan. There are 77 residents in Assisted Living and 22 residents in Memory Care for a total of 99 residents in care. There are residents receiving hospice care services within the approved hospice waiver. Required postings were observed.

LPA/Administrator toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. The memory care unit is on a delayed egress system and a locked perimeter courtyard for resident use, which it was approved in their fire clearance. There are evacuation chairs located at each stairwell. The elevators were last inspected on 7/16/25 and permit expires on 7/16/26. The facility was a comfortable temperature. Passageways were free of obstructions. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under three minutes. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Refrigerators and freezers were at required temperatures. Prepared and left over foods were covered and labeled. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The facility has a generator in case of power outages.

At approximate 9:28am and 9:43am, LPA/Administrator observed one maintenance shop and two laundry rooms located in assisted living unit were unlocked. Other cleaning products that were observed on the floor were supervised and/or locked carts. Continued on LIC 809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: PINE RIDGE TERRACE
FACILITY NUMBER: 496804280
VISIT DATE: 01/15/2026
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Continued from LIC809...
Residents were observed participating in group activities in common areas. There are activities written on a board specified for both assisted living and memory care engagement. The last fire drill was conducted December 2025. The fire alarm and sprinkler system was last inspected October 2025. Fire extinguishers were observed to be last charged on 10/2025. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected October 2025. Water temperatures measured at between 115.7 and 118.6 degrees (F) which is within acceptable range of 105 to 120 degrees F. Bathrooms have non-skid surfaces and grab bars at the toilet and shower areas. All medications were all locked and inaccessible to residents in care.

- At 10:20 AM, LPA conducted a file review of ten staff and ten residents. LPA observed three out of ten staff individuals (I1, I2 & I3) were fingerprint cleared, but their fingerprints have not been transferred and associated to the facility. LPA informed Administrator that staff (I1, I2 & I3) are not associated to facility and should never be working and providing care to residents prior to a criminal record clearance transfer. Civil penalties are being assessed in the amount of $100 per person for a total amount of $300 for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance transfer and association. One out of ten staff (S1) do not have a health screening form on file including their TB test (technical violation issued). Five out of ten staff (S3, S4, S5, S7 & S9) do not have current 1st aid or CPR certificates updated, but there is at least one staff on shift that has a valid CPR/1st aid certificate (technical violation issued). Six out of ten staff (S1, S2, S4, S6, S7 & S8) have not completed all required training hours. According to Administrator, effective on 6/30/25 there was a change of management that resulted in a different vendor for staff training and previous management kept training records (technical violation issued). Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. Karina Tapia, administrator certificate 7029240740 expires on 11/20/2026. Medications and medication records were reviewed. Annual fees are not current, but LPA was informed by the operations administration director that they have the invoice on hand and the financial department is working on submitting a payment timely.

Administrator agrees to submit updated documents by 2/6/26: LIC500Personnel Report & Liability Insurance.


Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, and the Health and Safety Code. Civil penalties in the amount of $300.00 is being assessed due to staff not being associated to facility. Appeal Rights Given. Exit interview conducted with Administrator and copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 03:49 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/15/2026 at 03:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PINE RIDGE TERRACE
FACILITY NUMBER: 496804280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in three out of ten staff individuals (I1, I2 & I3) were fingerprint cleared, but their fingerprints have not been transferred and associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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LPA confirmed I1, I2 & I3 has cleared finger prints. Administrator agrees to email/fax required documents to CCL to associate individuals who two of them were working and present at the facility at the time of inspection to clear the citation. ***Civil Penalty assessed in the amount of $300 for each staff not associated to this facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 03:49 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/15/2026 at 03:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PINE RIDGE TERRACE
FACILITY NUMBER: 496804280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation and interview, the licensee did not comply with the section cited above in one maintenance shop and two laundry rooms located in memory care and assisted living unit were unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator will provide a LIC 9098 Proof of Corrections self certifying that CCR Regulation 87309(a) was reviewed with Assisted Living staff by POC due date of 2/6/2026 to clear the citation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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