496804112-1-12-2026-21-AS-BMOS-DSZLQF-20260410085724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 01/12/2026
Date Signed: 01/12/2026 04:41:30 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
12/18/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20251218115655

FACILITY NAME:	IVY PARK AT PINER		FACILITY NUMBER:	496804112
ADMINISTRATOR:	PERRY, ERIC		FACILITY TYPE:	740
ADDRESS:	1980 PINER ROAD		TELEPHONE:	(707) 852-2234
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	92	CENSUS:	DATE:	01/12/2026
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Eric Perry-Administrator		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff are not giving resident medications as prescribed
Violation of resident's personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, at approximately 9:45am on 1/12/26, and met with Eric Perry, Administrator, and Dori Elder, Resident Care Coordinator.

Reporting party (RP) alleges that "staff are not giving resident medications as prescribed, and violation of resident's personal rights."

LPA reviewed resident R1's records, including admission records, medical assessment, care plan, medication mars/medication log, Kaiser Dr's Orders, legal power of attorney (POA) paperwork, and legal court ordered "temporary restraining order" currently in effect. Interviews were conducted with staff, S1, S2, and S3, and interviews with other related parties.

The investigation revealed that medications for resident, R1, are being provided as prescribed by the Physician; Medications are prescribed for specific health diagnosis of R1, and are being provided to them as ordered, per review of medication records.
Continued on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026

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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Control Number 21-AS-20251218115655

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: 01/12/2026

NARRATIVE

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Per review of records, staff have provided medications for R1 to have while away from the facility. Per review of records, there is a legal representative, POA, power of attorney for R1, which is still in effect. There are no new court orders and/or approvals on change of current POA.

The POA ensured resident had prescribed medications ordered and obtained, when the medications didn't return back with the resident, upon R1's return to them. R1's medications are filled by Kaiser Pharmacy regularly for resident R1. Per review of records, and conducted interviews, there was no information obtained in the investigation to support that a violation had occurred.

The resident/R1 has visitors that come to the facility to visit, including some family members who visit, and take resident out of the community as well. Per interviews with staff, and other related parties, visitation is not being withheld from R1, and resident is not being isolated from others. Per staff interviews, and interviews with other parties, there is a legal temporary restraining court order in effect at this time.

Per review of records, there is a temporary restraining order, In summary it states, individual, (I1), is restricted to one (1) supervised visit a week with R1, for a period of one (1) hour. The supervised visit must take place at the facility, Ivy Park At Piner, and must be pre-scheduled with Cheryl Fox, RN. This is in effect until the "end of the court date of 1/14/26".

Per interview with facility staff, S1, the facility is following the legal court restraining order, and will contact parties as required/needed, including local police department if needed at any time, regarding the temporary restraining order. Per review of records, and conducted interviews, there was no information obtained in the investigation to support that a violation had occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations of "staff are not giving resident medications as prescribed, and violation of resident's personal rights" 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.
Complaint Report LIC9099 was provided to the Administrator.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026

LIC9099 (FAS) - (06/04)

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