097004177-3-19-2025-59-AS-KHOS-DF4PGJ-20250325111825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097004177
Report Date: 03/19/2025
Date Signed: 03/19/2025 10:19:44 AM

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
11/05/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20241105091005

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: 172	DATE:	03/19/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrato Landon Pilegaard		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff's negligence and lack of supervision resulted in resident's fall.

INVESTIGATION FINDINGS:

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On March 19, 2025, 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: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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 4

Control Number 59-AS-20241105091005

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: 03/19/2025

NARRATIVE

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Staff's negligence and lack of supervision resulted in resident's fall.
Department conducted record review, staff, and resident interviews to investigate this allegation. Facility records show that R2 was independent and was able to ambulate independently with an ambulation device (walker). Staff were instructed to remind R2 to use their walker when ambulating. R2’s needs and service plan did not indicate R2 was a fall risk or that R2 needed additional supervision based on history of falls. Based upon the information obtained during investigation, the above 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.

Exit interview conducted. Report left with facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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
11/05/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20241105091005

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: 172	DATE:	03/19/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrato Landon Pilegaard		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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9

Staff administered an overdose of prescribed medications that resulted resident's death.

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: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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-20241105091005

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: 03/19/2025

NARRATIVE

1
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Staff administered an overdose of prescribed medications that resulted resident's death.
Records were reviewed regarding the death of R1. The Department was unable to obtain information that R1 was overmedicated by facility staff. Based on R1’s death certificate, cause of death was listed as Alzheimer's Disease, therefore, the above 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. Report left with facility representative.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4