097004177-10-11-2023-59-AS-LMUZ-CWKUGR-20231013153448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097004177
Report Date: 10/11/2023
Date Signed: 10/11/2023 09:38:59 AM

Unfounded

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
08/03/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230803115533

FACILITY NAME:	PONTE PALMERO		FACILITY NUMBER:	097004177
ADMINISTRATOR:	KASNER, GREGORY		FACILITY TYPE:	740
ADDRESS:	3083 PONTE MORINO DRIVE		TELEPHONE:	(530) 677-9100
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	250	CENSUS: 177	DATE:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Landon Pilegaard		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Staff did not prevent resident from being injured by another resident
Staff did not provide written incident report to resident's responsible party within 7 days
Staff do not assist resident with incontinence needs

INVESTIGATION FINDINGS:

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On 10/11/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Landon Pilegaard.

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**

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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 59-AS-20230803115533

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: PONTE PALMERO	FACILITY NUMBER: 097004177
	VISIT DATE: 10/11/2023

NARRATIVE

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Staff did not prevent resident from being injured by another resident.
Based on interviews conducted with staff and with residents on 8/9/23 and 9/12/23. On 7/19/23 an incident was reported that a resident was moving in their wheelchair and accidentally grazed R1 on the leg. R1 sustained a bruise, however, did not sustain any additional injuries. Although R1 was injured by a resident’s wheelchair, the incident was an accident and did not occur again therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff did not provide written incident report to resident's responsible party within 7 days
Based on records reviewed and interviews it was determined that staff notified R1’s responsible party of an incident that occurred at the facility on 7/19/23, the same day the incident occurred. Upon review, it was also found that the facility notified the Department of the incident on 7/26/23 within 7 days per Title 22 requirements. Therefore, this allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff do not assist resident with incontinence needs
Regarding the allegation that staff do not assist residents with incontinence care, LPA met with several residents, spoke with several staff, and reviewed documentation. LPA learned that residents are checked regularly, at least every couple of hours, and staff assist residents with continence and incontinence per needs and service plans. Staff are aware of those residents who may need more frequent or extra assistance and monitor them. At this time, residents are changed when needed based on their needs and service plan. Therefore, the allegation is 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. Copy of report left at facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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