496804112-5-1-2025-21-AS-DALO-DG9TX3-20250501150628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804112
Report Date: 05/01/2025
Date Signed: 05/01/2025 03:06:37 PM

Document Has Been Signed on 05/01/2025 03:06 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	LODGE AT PINER ROAD, THE		FACILITY NUMBER:	496804112
ADMINISTRATOR/ DIRECTOR:	PERRY, ERIC		FACILITY TYPE:	740
ADDRESS:	1980 PINER ROAD		TELEPHONE:	(707) 852-2234
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 92		CENSUS: 75	DATE:	05/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Eric Perry-Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alviso conducted Required - 1 Year inspection, on 5/1/25 at approximately 9:20am, and met with Administrator Eric Perry. LPA toured the facility, assisted living, including the memory care unit, with Administrator Eric Perry, and Maintenance Director, Abraham Bautista.. Facility has an approved dementia plan of operation. There is an approved hospice waiver for twenty (20) residents. Fire clearance is approved for ninety-two (92) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has an infection control plan as required. Facility has emergency food and other emergency supplies to meet the seventy-two (72) hour shelter in place requirements. Per emergency disaster drill records, last emergency disaster drill was conducted on 4/17/25, and 3/20/25. LPA reviewed ten (10) resident files. All files were complete. LPA reviewed ten (10) staff files. LPA reviewed staff training. All staff had criminal record clearance as required. The first floor is all assisted living, and the second floor is assisted living, which also houses a memory care unit. All stairwells, total of three (3), had the required evacuation chairs, and instructions posted on how to use the chair. All exits were observed to be free and clear of obstruction. The memory care unit, and assisted living areas were observed to be clean and orderly, The memory care has a keypad for entry into the memory unit, through a delayed egress door. There was sufficient lighting in the facility, in all hallways, common areas, and observed resident rooms and bathrooms for residents' use. Continued on LIC809C,,,

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LODGE AT PINER ROAD, THE	FACILITY NUMBER: 496804112
	VISIT DATE: 05/01/2025

NARRATIVE

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The medication rooms have medications centrally stored, locked up, and inaccessible to residents in care, and inaccessible to staff that that are not trained to assist residents with medications; There were small refrigerators in the medication rooms, for medications that need to be refrigerated. LPA reviewed medication records and medication logs, for routine medications, narcotic medications, and PRN medications.

Housekeeping carts observed in the facility were found to be locked, making cleaners/disinfectants inaccessible to residents in care. Bathrooms have grab bars, and non-slip flooring/mats for residents use. Hot water was measured at 116.4 and 118.2 degrees Fahrenheit, which is within regulation. Fire extinguishers that were checked were found to be serviced and tagged as required. Facility had sufficient paper products, cleaners/disinfectants, and personal protective equipment (PPE). There is an outside courtyard patio for resident use in the memory care, which includes patio furnishings. The assisted living area has outside patios for residents use.

LPA observed some of the memory care residents participating in an activity, chair exercise game, being provided by the staff. LPA observed AL residents preparing to go out on an activity in the community. The facility has activities in the facility for all residents, and has various outings into the community for memory care residents, and assisted living residents, as part of the activity calendar.

LPA is requesting the following documents be updated and submitted by 6/1/25.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees.
Copy of current Administrator Certificate
Copy of current Liability Insurance.

There were no deficiencies cited during today's inspection.
Exit interview was conducted with the Administrator, Eric Perry.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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