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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 092700445
Report Date: 09/04/2025
Date Signed: 09/04/2025 11:53:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2025 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20250711083845
FACILITY NAME:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
092700445
ADMINISTRATOR:WALL, ALISON MFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:64CENSUS: 54DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Kim DelgadoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not ensuring that residents' medical records are documented appropriately.
Staff are not ensuring that residents receive their medications as prescribed.
Staff are not reporting incidents as necessary.
Licensee does not ensure facility is in good repair.
Lack of supervision resulted in resident eloping from the facility
Licensee does not ensure that residents are provided a safe environment.
INVESTIGATION FINDINGS:
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On 9/4/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Kim Delgado.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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 6
Control Number 59-AS-20250711083845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PAVILION AT EL DORADO HILLS, THE
FACILITY NUMBER: 092700445
VISIT DATE: 09/04/2025
NARRATIVE
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The facility was issued citations on 07/15/2025 during a case management visit for the allegations of:
Staff are not ensuring that residents' medical records are documented appropriately.
Staff are not ensuring that residents receive their medications as prescribed.
Staff are not reporting incidents as necessary.
Licensee does not ensure facility is in good repair.
The Department conducted a record review, resident and staff interviews, and facility observation during complaint opening visit on 7/15/25. It was observed that resident medical records and medications were not managed or properly documented per Title 22 Regulations. Furthermore, it was noted that the facility was not reporting multiple incidents per reporting requirement to the department. Facility observations indicated that residents call system was nonfunctional for an unknown time. Based on the information gathered, all the above allegations were substantiated. Although the allegations are substantiated, citations will not be issued as the violations have already been addressed on 07/15/2025 in a case management visit.


Lack of supervision resulted in resident eloping from the facility
Licensee does not ensure that residents are provided a safe environment.
The Department conducted a record review, resident and staff interviews, and facility observation during complaint investigation visits on 7/15/25 and 7/24/25. Record review indicated that residents were eloping from the facility on more than one occasion without staff assistance or supervision. Residents’ medical assessment, LIC 602 indicated that their primary diagnosis was dementia and cannot leave facility unassisted. Staff interviews indicated that sometimes residents elope due to a delay in the egress system which was not operating properly. Based on the information gathered, above allegations are SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted, deficiencies cited on LIC809D per Title 22, and appeal rights were given.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20250711083845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAVILION AT EL DORADO HILLS, THE
FACILITY NUMBER: 092700445
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2025
Section Cited
CCR
87411
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by;
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Administrator shall conduct staff training, regarding AWOL risk for residents, every month until December 2025 and will send training documents to CCL. Outline of training shall be sent to CCL by 9/5/25.
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Based on records of residents, it was concluded that more than one resident was able to AWOL from the facility, unassisted, which poses an immediate risk to the health and safety of residents in care.
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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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2025 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20250711083845

FACILITY NAME:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
092700445
ADMINISTRATOR:WALL, ALISON MFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:64CENSUS: 54DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Kim DelgadoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility not meeting resident's ADLs
Licensee does not ensure that staff are adequately trained.
INVESTIGATION FINDINGS:
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On 9/4/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Kim Delgado.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:


**Report continued on 9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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 6
Control Number 59-AS-20250711083845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PAVILION AT EL DORADO HILLS, THE
FACILITY NUMBER: 092700445
VISIT DATE: 09/04/2025
NARRATIVE
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Facility not meeting resident's ADLs
The department conducted interviews, facility observation and record review to investigate the above allegation. During interviews with facility staff and residents, it has been discovered that facility provided appropriate care to the residents based on resident’s documented needs and service plans. During department visits on 7/15/25 and 7/24/25, the Department observed that staff were attentive to residents’ care needs and helping them with their care needs. Staff interviews reflected the fact that the facility provides adequate staffing and there were no issues with staff not helping residents with their care needs. Staff stated that they were assisting residents with toileting needs every 2 hours or as needed without any issues. Resident interviews did not express any concerns in this area; therefore, this allegation is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Licensee does not ensure that staff are adequately trained.
The Department conducted interviews with staff members and reviewed records regarding the allegation above. Staff interviews revealed that staff have adequate training (on boarding and ongoing) regarding infection control guidelines and other required topics and there were no issues. Staff interviews also reflected that the facility has adequate supplies of PPE and other care items to take care of residents. Record reviews indicated that the facility has all the required documentation regarding staff training per Title 22 Regulations, therefore these allegations were found to be UNSUBSTATIATED. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Report left with facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2025 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20250711083845

FACILITY NAME:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
092700445
ADMINISTRATOR:WALL, ALISON MFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:64CENSUS: 54DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Kim DelgadoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff member is under the influence while at the facility.
INVESTIGATION FINDINGS:
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On 9/4/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Kim Delgado. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

This agency has investigated the complaint alleging staff at the facility are working under the influence. Based on interviews and observation, the department has not found any evidence that the allegation is true therefore the Department finds the allegation to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. Report left with facility.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6