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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097004177
Report Date: 02/06/2024
Date Signed: 02/06/2024 01:51:34 PM


Document Has Been Signed on 02/06/2024 01:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:PONTE PALMEROFACILITY NUMBER:
097004177
ADMINISTRATOR:PILEGAARD, LANDONFACILITY TYPE:
740
ADDRESS:3083 PONTE MORINO DRIVETELEPHONE:
(530) 677-9100
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:250CENSUS: 152DATE:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adinistrator Landon PilegaardTIME COMPLETED:
02:10 PM
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Licensing Program Analysts (LPA) Lavinia Muscan arrived on 2/6/2024 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (15) and staff (10) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA and Administrator Landon Pilegaard toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, kitchen, hallways, memory care apartments, memory care dining room/kitchen, and memory care common areas. Water temperatures in the apartments toured were within the required range of temperature. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month.

Exit interview conducted. A copy of this report was printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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