097004177-9-17-2024-59-AS-MSEY-D9LPQG-20240930113106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097004177
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:30:26 PM

Unsubstantiated

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
05/21/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20240521225759

FACILITY NAME:	PONTE PALMERO		FACILITY NUMBER:	097004177
ADMINISTRATOR:	PILEGAARD, LANDON		FACILITY TYPE:	740
ADDRESS:	3083 PONTE MORINO DRIVE		TELEPHONE:	(530) 677-9100
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	250	CENSUS: 176	DATE:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator Landon Pilegaard		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff neglect resulted in a resident to be hospitalized
Staff left a resident unattended

INVESTIGATION FINDINGS:

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On 9/17/24, 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**

Unsubstantiated

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: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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 4

Control Number 59-AS-20240521225759

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: 09/17/2024

NARRATIVE

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Staff neglect resulted in a resident to be hospitalized - UNSUBSTANTIATED
Staff left a resident unattended - UNSUBSTANTIATED
Based on interviews and record reviewed, it was determined that based on R1’s resident assessment/care plan, R1 was able to independently bathe, dress, feed, toilet, manage cash, administer medications, and store medications on their own. R1 was able to independently transfer to and from bed. R1 did not require additional checks. R1’s resident assessment was completed approximately every six months without any major updates. Prior to R1’s hospitalization, R1 did not have any incidents of falling or sustaining injuries. Additionally, facility staff were checking on R1 three times a day which was the standard amount. R1 did not require additional checks and did not require checks during the NOC shift, therefore the allegations are found to be 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.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
05/21/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20240521225759

FACILITY NAME:	PONTE PALMERO		FACILITY NUMBER:	097004177
ADMINISTRATOR:	PILEGAARD, LANDON		FACILITY TYPE:	740
ADDRESS:	3083 PONTE MORINO DRIVE		TELEPHONE:	(530) 677-9100
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	250	CENSUS:	DATE:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator Landon Pilegaard		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not ensure a resident's emergency pendant was properly operating
Staff did ensure the facility's radio was properly operating
Staff did not meet a resident's hygiene needs

INVESTIGATION FINDINGS:

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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: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20240521225759

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: 09/17/2024

NARRATIVE

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Staff did not ensure a resident's emergency pendant was properly operating - UNFOUNDED
Staff did ensure the facility's radio was properly operating - UNFOUNDED
Based on interviews and record reviewed, it was determined that the facility radio, along with the emergency pendant was operating properly. Documents show that R1’s pendant was pressed, and the pull switch was pulled, and the connection was delivered to radio/staff who responded within four minutes, therefore the above allegations are 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 meet a resident's hygiene needs - UNFOUNDED
Based on interviews and record reviewed, it was determined that based on R1’s resident assessment/care plan, R1 was able to independently bathe, dress, feed, toilet, manage cash, administer medications, and store medications on their own. R1 was able to independently transfer to and from bed. R1 did not require additional checks, therefore the above allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4