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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 12/02/2025
Date Signed: 12/02/2025 05:13:04 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
11/25/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251125153312
FACILITY NAME:IVY PARK AT PINERFACILITY NUMBER:
496804112
ADMINISTRATOR:PERRY, ERICFACILITY TYPE:
740
ADDRESS:1980 PINER ROADTELEPHONE:
(707) 852-2234
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:92CENSUS: DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:DORI ELDER- RESIDENT CARE COORDINATORTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 10:00am on 12/2/2025, and met with Dori Elder, Resident Care Coordinator, and Monica Hernandez, Memory Care Coordinator.

Reporting party alleges that "facility staff hit resident." There were no staff names, of who hit the resident, able to be provided with the allegation reported. LPA reviewed resident R1's records, including admission records, medical assessment, care plan, appraisal, medications/Dr's Orders, and resident incidents.

LPA requested copies of records; LPA was provided the requested copies during the inspection. LPA conducted interviews with staff, and other related parties.

The investigation revealed that R1 has a current care plan in place, all care needs listed, and updated medications list. R1 is escorted to all meals and activities as needed per care plan. R1 does have a responsible party that is involved, and visits regularly with R1.

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

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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 2
Control Number 21-AS-20251125153312
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: IVY PARK AT PINER
FACILITY NUMBER: 496804112
VISIT DATE: 12/02/2025
NARRATIVE
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LPA reviewed documented incident progress notes regarding the resident, and incidents reported. Per the investigation there was no information obtained to support a violation had occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation of "facility staff hit resident" is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited.
Exit interview was conducted with Dori Elder, Resident Care Coordinator
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2