097004177-4-8-2025-59-AS-LMUZ-DFQUTA-20250414155136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097004177
Report Date: 04/08/2025
Date Signed: 04/08/2025 10:42:11 AM

Substantiated

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
08/28/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20240828164917

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: 173	DATE:	04/08/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Landon Pilegaard		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable Death
Neglect/lack of care and supervision resulted in staff failing to seek timely medical attention
Neglect/lack of care and supervision resulting in residents in care sustaining multiple falls with a serious injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On April 8, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains 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**

Substantiated

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: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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 7

Control Number 59-AS-20240828164917

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: 04/08/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Questionable Death

Records were reviewed regarding the death of R1. On June 18, 2024, at about 0144 hours, R1 was admitted to the emergency department due to a recent unwitnessed fall and sustained a head injury with a hematoma on their left ear. R1 was found on the ground between approximately 0100 hours and was last seen by Ponte Palmero staff in bed at 2300 hours. R1 was admitted to the hospital due to the blunt/critical trauma level II and diagnosed with a subdural hematoma, hematoma of the left ear, and falls. Due to the severity of R1’s injuries, R1 was place on comfort care. On June 29, 2024, R1 passed away. Certificate of Death indicated that R1 died from cardiac arrest and a traumatic brain injury with a subdural hematoma. R1’s facility file documents, Physician’s Report, Resident Assessment, Resident Charting Notes, Incident Reports, and Needs and Services plans, revealed that R1 was documented as being a fall risk, using a walker to ambulate, and having unsteady gait. R1 was admitted to Ponte Palmero Memory Care Unit on August 23, 2022. Records indicated R1 fell (7) seven times on 10/2/2023, 11/29/2023, 1/31/2024, 3/30/2024, 4/29/2024, 5/3/2024, and 6/18/2024. R1 only had two Resident Assessment’s dated August 18, 2023, and September 30, 2023, that indicated R1 needed more standby assistance. R1 did not receive any additional care services, such as an alarm mat, to prevent them from falling. Memory Care Director, Dej’ja Bracy stated that R1 was not considered a fall risk and did not need a fall prevention plan. Former staff mentioned R1 was independent, however could be considered a fall risk and noticed a change in R1’s ability to walk or to get out of bed. Based on department record review and interviews conducted, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $500 is assessed.

Page 1 continued on 9099-C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 59-AS-20240828164917

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: 04/08/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Neglect/lack of care and supervision resulted in staff failing to seek timely medical attention for residents.

Neglect/lack of care and supervision resulting in residents in care sustaining multiple falls with a serious injury.

R1
On June 18, 2024, Emergency Medical Services were contacted at about 0104 hours, EMS arrived at the facility at about 0117 hours, and transported R1 to the Hospital at 0141 hours. It is unclear the time frame between R1 falling and the staff contacting 911. The incident report completed by staff indicated that R1 was found on the floor at about 0128 hours. Documents obtained did not appear to accurately reflect the time frame of when R1 was found by staff and when EMS was contacted. Interviews and documentation revealed that prior to calling 911, S1 contacted Ms. Bracy for direction and Ms. Bracy directed S1 to contact R1’s responsible party to inquire with R1’s family would transport R1 the hospital. R1’s responsible party directed S1 to call 911. S1 estimated it took about 20 minutes. Interview with S1 indicated S1 remembered R1 telling them that R1 had been on the floor for hours and found R1 with a visible head injury and was bleeding from their left ear.

R1 was admitted to Ponte Palmero Memory Care Unit on August 23, 2022. Documents revealed R1 fell
seven times on 10/2/2023, 11/29/2023, 1/31/2024, 3/30/2024, 4/29/2024, 5/3/2024, and 6/18/2024 while in care. Interview Memory Care Director Dej’ja Bracy stated that R1 was not considered a fall risk and did not need a fall prevention plan. R1’s medical records and facility documents show that R1 was a fall risk. The facility failed to update R1’s care after multiple falls and change in condition.

Page 2 Continued on 9099-C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 59-AS-20240828164917

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: 04/08/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R2

On April 29, 2024, at about 0921 hours, R2 was admitted to the Hospital and diagnosed with a
closed fracture of neck of left femur, pneumonia of both lungs, dementia, hypomagnesemia, and a
closed fracture of left hip. R2’s notes indicated that they woke up in morning, was trying to get out
of bed, fell down, and was found at the side of the bed by the facility staff. R2 had a skin tear to
their left forearm, an abrasion to their left knee, and multiple bruises to their bilateral upper extremities. X-rays of the hip and pelvis showed a left hip fracture and chest x-ray showed possible bibasilar pneumonias. R2 required surgery to repair the hip. On May 3, 2024, R2 was discharged to Ponte Palmero with hospice care. Ponte Palmero had two LIC624 Unusual Incident/Injury Reports dated April 29, 2024. The first incident report documented on April 29, 2024, at about 0040 hours, Med Tech S1 found R2 on the floor by the front of the bed with a small skin tear to their left wrist, an abrasion to their left knee, and a small abrasion to the small finger on the right hand. The second incident report documented on April 29, 2024, at 0800 hours, S2 notified R2’s responsible party of R2’s fall. S2 explained that R2's responsible party came to the facility to try to take R2 to see a doctor and was unable to. R2’s responsible party requested for S2 to contact 911. Statements with staff were consistent that R2 fell on 4/29/2024 at 0040 hours, placed back in bed and was not transported to the hospital until at 0800 hours. R2 did not receive immediate medical attention despite having pneumonia and displaying signs of being in severe pain. S3 recalled putting R2 back into bed and R2 expressing that they were in pain. R2 did not get medical attention until 8 hours after their fall, therefore the facility failed to seek timely medical attention.

Page 3 Continued on 9099-C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 59-AS-20240828164917

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: 04/08/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R3

On April 7, 2024, at about 0023 hours, R3 was admitted to the emergency department and was diagnosis with a community acquired pneumonia, left intertrochanteric femur fracture, and gastroesophageal reflux disease (GERD). R3 had surgery to a cephallomedullary nail placement.
On April 13, 2024, R3 was discharged to a Skilled Nursing Facility for rehabilitation. Ponte Palmero had two LIC624 Unusual Incident/Injury Reports dated April 4, 2024, documenting that at about 1315 hours, R3 was found on the floor in their bathroom. R3 did not have any apparent injuries. The second incident report documented that at about 1515 hours, R3 complained of body aching, pain, and coughing more than usual. 911 was called and R3 was taken to the Hospital. R3’s PCP and family were notified. The second incident report was documented inaccurately as R3 was admitted to the hospital on April 7, 2024. The facility did not have any incident reports documenting R3’s hospital visits on April 7, 2024.
Several staff interviews revealed that R3 fell off the toilet on April 4, 2024, and was placed back in
bed for a few days prior to being sent to the hospital on April 7, 2024. Interviews indicated S4 was supposed to be supervising R3 while R3 was using the bathroom, but S4 stepped away from R3 and R3 fell. S4 called S5 and Ms. Bracy to come assess R3’s injuries. R3 was in pain, but S5 and Ms. Bracy placed R3 in a wheelchair. R3 did not go to the hospital on April 4, 2024, when R3 sustained their fall and was taken three days later on April 7, 2024. Interviews with S5 and Ms. Bracy revealed similar statements of R3 falling in their room and helping R3 back into a wheelchair but did not recall R3 being in any pain. S5 and Ms. Bracy indicated they were aware that R3 sustained a fractured femur and returned to the facility.

R3 was admitted to Ponte Palmero on August 21, 2019. R3 was documented as having
16 falls on 10/24/2020, 2/17/2021, 2/27/2021, 6/29/2021, 12/17/2021, 1/23/2022, 3/29/2022, 5/4/2022, 5/9/2022, 8/29/2022, 9/1/2023, 3/11/2024, 3/24/2024, 4/4/2024, 5/17/2024, and 6/27/2024. Staff statements revealed consistently that R3 was considered a fall risk and could not walk or barely stand on their own. R3 may have been documented as a fall risk; however, the facility failed to have a fall plan in place at the time of R3’s fall on June 27, 2024, resulted in R3 sustaining an intertrochanteric femur fracture.

Page 4 Continued on 9099-C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 59-AS-20240828164917

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: 04/08/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R4
Based on documentation obtained, R4 sustained a fall on June 27, 2024, which reported the facility failed to seek timely medical attention. On June 27, 2024, at about 0752 hours, R4 was seen in the ER due to a fall and diagnosed with a UTI, a closed head injury, contusion of the right orbital tissues, and an abrasion to their face. R4 had an unwitnessed fall in an unknown location. R4 was found on the floor at Ponte Palmero’s Memory Care Unit. On June 27, 2024, at about 1302, R4 was discharged to return to Ponte Palmero. R4’s LIC624 Unusual Incident/Injury Reports documented that on June 27, 2024, at about 0624 hours, R4 was found on the floor next to their bed, lying face down with swelling and a small laceration on their right side of face. R4’s responsible party was notified twice, and a voice message was left. 911 was contacted and R4 was taken to the hospital. Hospital medical records revealed R4 arrived at about 0752 hours and was diagnosed with a closed head injury, contusion of the right orbital tissues, and an abrasion on R4’s face. S2 stated that after R4’s fall on June 27, 2024, it took too long to get R4 medical attention. S2 explained that Ms. Bracy did not allow S2 to contact 911 and Ms. Bracy told S2 to get ahold of R4’s responsible party to take R4 to the hospital.

R4’s Narrative Charting, LIC624 Unusual Incident/Injury Reports, and hospital medical records indicated that R4 fell a total of eight times on 5/3/2024, 5/14/2024, twice on 5/21/2024, 6/27/2024, 6/30/2024, and twice on 7/2/2024. Staff interviews revealed consistent statements of noticing a change in R4’s behavior and R4 falling frequently within a small timeframe. Staff expressed their concerns for R4’s frequent falls; however, the facility failed to adequately develop a fall plan to reduce potential falls for R4.
Based on Ponte Palmero’s Fall Procedures, procedure indicates that if a resident has any trauma resulting in deformities or significant trauma, then Emergency Medical Services (EMS) should be contacted. R1, R2, R3 and R4 sustained falls which resulted in significant trauma. Facility failed to follow their fall procedures thereby failing to seek timely medical attention for R1, R2, R3 and R4.

Based on records obtained and interviews conducted, the facility failed to provide care and supervision to residents who sustained multiple falls with a serious injury. Additionally, facility did not seek timely medical attention for resident’s who sustained injuries due to falls. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $500 is assessed.The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49. Exit interview conducted. Appeal rights provided. Report left with facility Administrator.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 59-AS-20240828164917

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/09/2025 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	The administrator agrees to write a plan of correction detailing how facility will address reassessments for resident’s who are documented fall risks. Additionally, the facility agrees to submit a plan on how staff will be trained and notified of resident’s who are fall risks and fall prevention protocols for each resident.
	8 9 10 11 12 13 14	This requirement was not met based on facility failed reassess R1 and R3 after residents sustained multiple falls, some resulting in injury. R1 sustained 7 falls within an 8-month period and R3 sustained 16 falls between 10/24/2020 and 06/27/2024. This posed an immediate Health and Safety risk to residents in care.	8 9 10 11 12 13 14
Type A 04/09/2025 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Timely medical 87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).	1 2 3 4 5 6 7	The administrator agrees to submit a plan on facility protocol when facility staff are to initiate emergency medical interventions, including when to call 9-1-1. The licensee shall ensure that all staff have been trained in managing a resident’s care. Licensee shall provide a training plan to the licensing agency regarding seeking medical care in a timely manner.
	8 9 10 11 12 13 14	This requirement was not met based on facility staff failed to seek medical attention for R1, R2, R3, R4 when residents sustained falls that resulted in serious bodily injury. This posed an immediate Health and Safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 7