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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804280
Report Date: 11/06/2025
Date Signed: 11/06/2025 06:13:44 PM

Substantiated


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
09/18/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250918163816
FACILITY NAME:PINE RIDGE TERRACEFACILITY NUMBER:
496804280
ADMINISTRATOR:TAPIA, KARINAFACILITY TYPE:
740
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:110CENSUS: DATE:
11/06/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Karina Tapia-AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff violated resident's personal rights

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 11/6/25 at approximately 9:45am, and met with Karina Tapia, Administrator, and Cheyenne Flores, LVN/Health Services Director

Reporting party alleges that "staff violated resident's personal rights." LPA reviewed resident records, care plan, medical assessment, medication records/medical records, and admission documents. LPA interviewed staff, and other related parties regarding the allegation. LPA obtained two photos that had been taken, by S3/staff member, of resident R1 who had fallen on the ground in their apartment unit. S3 took the pictures of R1, with their personal cell phone, prior to assisting the resident off the floor, and providing needed care to R1. The photos of R1 were identified to be taken on 7/24, during S3's shift, per date and time stamp of photo; LPA observed S3's cell phone number as the phone number that sent the pictures to the resident's cell phone days later after the incident.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
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 5
Control Number 21-AS-20250918163816
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: 11/06/2025
NARRATIVE
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Per investigation and interviews, the resident/R1 photos are found to be personal, confidential, humiliating, and violate R1’s personal rights. LPA has copies of photos for the file.
Per review of records, S3 was being written up by administration staff, for resident privacy and dignity violations of R1, as well as for a HIPPA violation;

There was sufficient information obtained in the investigation to support a violation had occurred. Based on record reviews, obtained photos, staff interviews, and interviews with other related parties, the allegation "staff violated resident's personal rights" is substantiated. Deficiency will be cited, 87468.2(a)(1)(3) Additional Personal Rights of Residents in Privately Operated Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.

Appeal rights provided with report.
Exit interview conducted with Cheyenne Flores, LVN/Health Services Director.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250918163816
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2025
Section Cited
CCR
87468.2(a)(1)(3)
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87468.2(a)(1)(3) Additional Personal Rights of Residents in Privately Operated Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement was not met as evidenced by:
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Licensee/Administrator to ensure all staff do not violate personal rights of residents’ in care. Staff are to be in-serviced on “Elder Abuse” training, and “Personal Rights of Residents” training. Submit proof of training, and plan of correction of the deficiency citation by 11/21/2025.
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LPA obtained two photos that had been taken, by S3/staff member, of resident R1 who had fallen on the ground in their apartment unit. S3 took the pictures of R1, with their personal cell phone, prior to assisting the resident off the floor, and providing needed care. stamp, and with S3's personal phone. Per investigation, and interviews, the resident/R1 photos are found to be personal, confidential, humiliating, and violate R1’s personal rights. LPA has copies of photos for the file. This is a violation of resident's personal rights.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/18/2025 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20250918163816

FACILITY NAME:PINE RIDGE TERRACEFACILITY NUMBER:
496804280
ADMINISTRATOR:TAPIA, KARINAFACILITY TYPE:
740
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:110CENSUS: DATE:
11/06/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Karina Tapia-AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff did not assist a resident with incontinent care needs

Staff made an inappropriate comment towards resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 11/6/25 at approximately 9:45am, and met with Karina Tapia, Administrator, and Cheyenne Flores, LVN/Health Services Director

Reporting party alleges that "staff did not assist a resident with incontinent care needs, and staff made an inappropriate comment towards resident." LPA reviewed resident records, care plan, medical assessment, medication records/medical records, and admission documents. LPA interviewed staff, and other related parties regarding the allegations.

The investigation revealed that R1's does have a care plan that addresses incontinent care. Per interviews, R1 does have a call alert pendant to use as needed, and R1 does understand how to use this device. R1 will ring pendant for incontinent assistance, and at other times chooses to not request staff assistance for incontinent care needs. Per record reviews and interviews, R1 is cheeckd on for incontinent care needs, and hygiene care needs, as well as bathing when needed; R1 sometimes declines being provided changes and showers at times.
Continued on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250918163816
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: 11/06/2025
NARRATIVE
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LPA was not able to obtain any supporting information of inappropriate comments being made by staff to resident/R1 and/or information of staff not providing incontinent care and violating resident rights with incontinent care services. There was no specific date and/or time of incidents of alleged violations that was able to be provided. LPA discussed and reviewed regulations with the Administrator regarding, personal rights of residents in care, and required training for all direct care staff. No information was obtained to support that violations of "staff did not assist a resident with incontinent care needs, and staff made an inappropriate comment towards resident." had occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations 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.


Exit interview conducted with Cheyenne Flores, LVN/Health Services Director.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5