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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804280
Report Date: 05/11/2026
Date Signed: 05/11/2026 06:14:38 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
03/16/2026 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20260316152654
FACILITY NAME:PINE RIDGE TERRACEFACILITY NUMBER:
496804280
ADMINISTRATOR:RODREICK, DONALDFACILITY TYPE:
740
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:110CENSUS: 102DATE:
05/11/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Don Rodreick-Administator/EDTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not meet residents' needs in a timely manner due to lack of staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 5/11/2026 at approximately 9:20am, and met with Don Rodreick, Administator/ED.

Reporting party alleges that "staff do not meet residents needs in a timely manner due to lack of staff".

LPA reviewed resident records, including medical records, care plan, medical assessment, and admission documents. LPA reviewed facility records, including medication records/MARS, care assessments, and staffing schedules for the memory care unit. LPA conducted interviews with staff, and other related parties. The investigation revealed that there are days in the month that direct care staff have called off work and the staff's shift was not covered, leaving the shift short one caregiver. The 6:00am to 2:00pm, and the 2:00pm to 10:00pm, shifts have three (3) direct caregivers, and a medication-thechnician scheduled to work, and the 10:00pm to 6:00am has two (2) direct caregivers on shift;This shift has a floating medication-technician that assists residents with medications in assisted living and memory care.

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

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
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 5
Control Number 21-AS-20260316152654
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: 05/11/2026
NARRATIVE
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In review of caregivers on shift in staff work schedules provided to the LPA, the following was identified:
On 2/16, 4/20, and 4/27, on the 6am to 2pm shift, there were only two (2) direct caregivers on shift.

On 2/8, 2/9, 2/10, 2/11, 2/12, 2/15, 2/16, 2/17, 2/18, 2/19, 3/5, 3/6, and 3/9 on the 2:pm to 10pm shift, there were only two (2) direct caregivers on shift.

On 3/7, on the 2pm to 10pm shift, there were only two (2) direct caregivers on shift. If a medication -technician calls out in memory care, the assisted living
medication -technician will cover the memory care resident medications.

Interviews conducted by the LPA, 1 through 9, supported that when the shift is down a caregiver it makes it difficult for some job duties/care needs to be done in a timely manner for residents in care. LPA observed a resident R6 who had their lower half of their body sliding out of their low bed, this was on 3/24/26 inspection, the resident was observed to need care, hygiene care, and dressing, their morning/late morning adls, for the day. LPA discussed this with the Administrator; The Administrator had staff go and assist R6 up, and with their ADLs. The LPA observed R6 later in the tour, to be cleaned, hair combed, appropriately dressed, and in the activity area with other residents. Per interviews, caregivers are expected to serve the meals to the memory care residents, clean the dining room, counters, gather all dishes, silverware, and clean the windows and floors from all meals.

The LPA identified that the dining room in the memory care unit was dirty, the glass windows, and door were dirty with smudged prints and grime, the floor covered with dirt, grime, crumbs, food, and some garbage. The LPAs shoes were sticking to the floor as it was dirty and very sticky. The memory care laundry room was dirty, floor dirty with garbage, and with torn flooring, Inspection date of 3/24/26 the laundry room sink was taken out, and a bucket was hanging off the faucet pipe. The laundry room is not in good repair, though it now has a sink put back in. LPA observed large pieces of lint on the small side patio table and chair outside in the memory care courtyard.

The hallways, activity rooms, and the medication room need a good floor cleaning, swept and mopped, including in the doorways, from garbage and debris seen in doorways, on the floors, and under desks/counter. LPA obtained pictures of the above items mentioned in the report. This will be cited in a case management report, LIC809/809D, dated 5/11/26.
Continued on LIC9099C..
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
03/16/2026 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20260316152654

FACILITY NAME:PINE RIDGE TERRACEFACILITY NUMBER:
496804280
ADMINISTRATOR:RODREICK, DONALDFACILITY TYPE:
740
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE:CAZIP CODE:
95403
CAPACITY:110CENSUS: 102DATE:
05/11/2026
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Don Rodreick-Administator/EDTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not provide adequate supervision to residents' due to lack of staff
Staff do not ensure residents' medications are administered in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 5/11/2026 at approximately 9:20am, and met with Don Rodreick, Administator/ED.
Reporting party alleges that "staff do not provide adequate supervision to residents due to lack of staff, staff do not ensure residents' medications are administered in a timely manner."
LPA reviewed resident records, including medical records, resident incidents, care plan, medical assessment, and admission documents. LPA reviewed facility records, including medication records/MARS, care assessments, and staffing schedules for the memory care unit. LPA conducted interviews with staff, and other related parties. There was no identified dates of residents not being provided adequate supervision by staff at a time, and/or any incidents due to lack of resident supervision. there is a window of time to provide medications to residents in care, 30 minutes before a dose is due and 30 minutes after a dose is due, an hour of time. There was no specific date and/or a resident (s) identified as having missed medications at any time. The assisted living medication technician and/or one of the facility's nursing staff can assist the residents in memory care with medications at any time if needed. The investigation revealed that there was not sufficient information to support that the above violations occurred.
Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.Exit interview conducted with Exit interview conducted with Don Rodreick, Administator/ED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260316152654
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: 05/11/2026
NARRATIVE
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Per investigation staff that call off shift in the memory care in the 6am to 2pm, and the 2pm to 10pm shifts are not covered regularly as needed to meet all job duties/care needs required by the staff to ensure residents needs are met in a timely manner.

Based on the investigation, record reviews, and interviews conducted, there was sufficient information obtained to support that a violation had occurred regarding "staff do not meet residents' needs in a timely manner due to lack of staff".

This deficiency will be cited, 87411(a) Personnel Requirements - General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

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 Don Rodreick, Administator/ED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20260316152654
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: 05/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2026
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Sufficient support staff shall be employed to ensure provision of personal assistance and care as required . Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.This requirement was not met as evidenced by:
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Administrator to ensure that all shifts in the memory care are staffed as needed and required to meet all residents needs in a timely manner. Ensure that the facility has sufficient staffing to meet other job duties that may not be direct care duties that the care staff can't complete due to their responsibilities with residents.
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Per investigation staff that call off shift in the memory care in the 6am to 2pm, and the 2pm to 10pm shifts are not covered regularly as needed to meet all job duties/care needs required by the staff to ensure residents needs are met in a timely manner. This is a risk to personal rights of the residents in care and/or a health & safety risk.
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 Please assess the needed staff for memory care, and a plan in filling scheduled staff that call out. Submit plan of correction and updated staff schedule, and duties of the memory care staff, ensuring sufficient staffing to meet all duties required by staff in memory care. POC due 5/26/26.
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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.
SUPERVISOR'S NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5