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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 12/08/2025
Date Signed: 12/08/2025 06:34:40 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
12/04/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251204145622
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:
12/08/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Eric Perry-AdministratorTIME COMPLETED:
06:35 PM
ALLEGATION(S):
1
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9
Staff did not provide resident's medication as prescribed
Staff mismanages resident's medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 10:45am on 12/8/2025, and met with Eric Perry, Administrator, and Dori Elder, Resident Care Coordinator. Reporting party (RP) alleges that "staff did not provide resident's medication as prescribed" and "staff mismanages resident's medications." RP was not able to provide any specific information on medications/prescribed medications. LPA reviewed resident R1's records, including admission records, medical assessment, care plan, medications/Dr's Orders, and documentation on incidents/progress notes. 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 staff are providing R1's medications as prescribed. Per interviews and record reviews, R1's medications are documented as required, and signed off by staff when provided to the resident. Per interviews conducted with other parties, there is question as to what medications are being provided by staff to R1, not that staff aren't providing medications as ordered. Per review, all resident R1's medications have Dr's Orders, and are provided to R1 per physician orders. There was no information obtained that supported a violation occurred regarding the allegation. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "staff did not provide resident's medication as prescribed" and "staff mismanages resident's medications." are 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 Eric Perry, Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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