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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097004177
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:38:12 PM


Document Has Been Signed on 07/11/2022 12:38 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:PONTE PALMEROFACILITY NUMBER:
097004177
ADMINISTRATOR:KASNER, GREGORYFACILITY TYPE:
740
ADDRESS:3083 PONTE MORINO DRIVETELEPHONE:
(530) 677-9100
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:250CENSUS: 169DATE:
07/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Gregory Kanser and Erick Olson TIME COMPLETED:
01:00 PM
NARRATIVE
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On 07/11/22, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility and met with Administrator Gregory Kanser and Executive Director (ED) Erik Olson, to do case management as follow-up on incident report received by the department on 07/01/2022 submitted by facility. Facility currently does not have any COVID-19 positive cases. LPAs wore surgical masks while in the facility.

On 07/01/22, the facility submitted an incident report to the department that alleged S1 slapped R1 on the face on 06/29/22 . This incident was witnessed and reported by another staff member. The facility conducted internal investigation and found the allegation to be true. S1 was terminated on 07/01/22 after the internal investigation. On 07/11/22, LPA s interviewed S2 ,R1 , administrator and ED. LPAs toured memory care unit on 07/11/22 .

Although the facility took steps to investigate this incident, S1 violated R1s personal rights therefore citation are being issued today as a result of S1 s actions.

LPAs requested medical records and other documents related to this incident for R1 from facility and facility will send all required documents to department by 07/13/22 .


As a result of today's inspection and records review deficiencies are cited pursuant to California Code of Regulations, Title 22. See LIC809D for citation issued today.

Exit interview was conducted with Administrator.
The signature of the Administrator on this acknowledges receipt of this document.

Appeal rights provided. Copy of this report left at the facility.


SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/11/2022 12:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: PONTE PALMERO
FACILITY NUMBER: 097004177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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This requirement is not met as evidenced by:
Based on facility incident reporting, records review and facility visit on 07/11/22, R1 s personal rights have been violated resulting S1 s termination from the facility.
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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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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