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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804280
Report Date: 12/04/2025
Date Signed: 12/04/2025 04:12:01 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
10/20/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251020095513
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:
12/04/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karina Tapia-AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff do not respond to call bell in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/4/25 at approximately 10:00am, and met with Karina Tapia, Administrator, and Cheyenne Flores, LVN/Health Services Director

Reporting party alleges that "facility staff do not respond to call bell in a timely manner." LPA reviewed resident records, including care plan, medical assessment, and admission documents.

LPA requested a copy of the alarm pendant report for R1's room, for month of October 2025; Staff provided the LPA with the copies requested. LPA interviewed staff, and other related parties regarding the allegation.

The investigation revealed that per review of alarm event report on R1's pendant for the month of October 2025, the following recorded dates, times, and elapsed time, of minutes & seconds, till staff responded to R1's call pendant read as follows:10/4 at 5:02am, elapsed time 24:23,10/4 at 2:09pm, elapsed time 17:47,

Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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 3
Control Number 21-AS-20251020095513
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: 12/04/2025
NARRATIVE
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on 10/5 at 2:49pm, elapsed time 21:15, on 10/8 at 2:25pm, elapsed time 18:06, on 10/10 at 8:15am, elapsed time 16:53, on 10/12 at 4:13pm, elapsed time 22:36, and on 10/17 at 3:50pm, elapsed time 24:19.

There was sufficient information obtained in the investigation to support a violation had occurred. LPA reviewed the alarm report and documented the above dates/times that staff didn't respond within a timely manner; Facility to ensure a timely response to call pendants for whatever is needed by the resident, including to ensure there is not an emergency response needed/required, such as 911 call out for the resident or incontinent care needs and/or medication assistance.

Based on record reviews, staff interviews, and interviews with other related parties, the allegation "facility staff do not respond to call bell in a timely manner." is substantiated. Deficiency will be cited, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, 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: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20251020095513
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: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee/Administrator to ensure that facility staff/direct caregivers are responding to all resident pendant calls, on all shifts, in a timely manner. Staff to respond in a timely manner to help ensure residents' needs are met as required, including emergency response/911 to be called if needed. Staff to be in-serviced in
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This requirement was not met as evidenced by: Per review of alarm event report on R1's pendant for the month of 10/2025, the following recorded dates, times, and elapsed time until staff responded to R1's call pendant, LPA documented calls that had a wait from 15 minutes to over 20 minutes for some, on 10/4 twice, 10/5, 10/8, 10/10, 10/12, and 10/17, see LIC9099. Facility staff failed to respond in a timely manner to R1's pendant calls listed. This is a risk to resident's personal rights & a risk to resident's health & safety.
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residents 'rights, and staff responsibility in answering pendant calls timely for all residents in care. Submit proof of training with direct care staff, all staff that answer to call pendants; Submit a plan of future compliance regarding the regulation and call pendant response by staff. POC due 12/19/25.
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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: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
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