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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097004177
Report Date: 09/13/2024
Date Signed: 09/13/2024 05:47:04 PM


Document Has Been Signed on 09/13/2024 05:47 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: 176DATE:
09/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Assisted Living Director Jennifer HinchTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Lavinia Muscan conducted unannounced case management visit on 09/13/2024. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPA met with Assisted Living Director and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 09/13/2024 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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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