Ponte Palmero

Type of visit: Case Management - Other

Licensing Program Analyst, Lavinia Muscan arrived on September 17, 2026, for an unannounced inspection. LPA met with facility representative, Lighthouse Director Jennifer Hinch, to follow up on substantiated allegations of neglect which resulted from a complaint investigation. On April 8, 2025, the Department concluded a complaint investigation regarding the following allegations: Neglect/lack of care and supervision resulted in residents in care sustaining multiple falls with serious injuries, Staff failed to seek timely medical attention for resident, and Questionable Death. The licensee was cited for California Code of Regulations (CCR) Title 22, § 87465(g) Timely Medical, and CCR Title 22, § 87466 Observation of the Resident. At the time of the case management inspection on April 8, 2025, an immediate civil penalty of $500.00 was issued and the licensee was informed that an additional civil penalty may be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by facility staff’s failure to obtain timely medical care and treatment for Resident (R2), after R2 sustained an unwitnessed fall while in care resulting in R2 suffering undue physical pain prior to R2’s surgical procedure for diagnosed hip fracture and subsequent hospitalization. Today, September 17, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department determines constitutes as serious bodily injury, in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on April 8, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Lighthouse Director Jennifer Hinch and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, Lavinia Muscan arrived on September 17, 2026, for an unannounced inspection. LPA met with facility representative, Lighthouse Director Jennifer Hinch, to follow up on substantiated allegations of neglect which resulted from a complaint investigation. On April 8, 2025, the Department concluded a complaint investigation regarding the following allegations: Neglect/lack of care and supervision resulted in residents in care sustaining multiple falls with serious injuries, Staff failed to seek timely medical attention for resident, and Questionable Death. The licensee was cited for California Code of Regulations (CCR) Title 22, § 87465(g) Timely Medical and CCR Title 22, § 87466 Observation of the Resident. At the time of the complaint visit on April 8, 2025, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by R1 falling while in care and facility staff failed to seek timely medical attention. R1 was hospitalized and later died as the result of the injuries. Today, September 17, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident, in the amount of $15,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Lighthouse Director Jennifer Hinch and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, Lavinia Muscan arrived on September 17, 2026, for an unannounced inspection. LPA met with facility representative, Lighthouse Director Jennifer Hinch, to follow up on substantiated allegations of neglect which resulted from a complaint investigation. On April 8, 2025, the Department concluded a complaint investigation regarding the following allegations: Neglect/lack of care and supervision resulted in residents in care sustaining multiple falls with serious injuries, Staff failed to seek timely medical attention for resident, and Questionable Death. The licensee was cited for California Code of Regulations (CCR) Title 22, § 87465(g) Timely Medical, and CCR Title 22, § 87466 Observation of the Resident. At the time of the complaint visit on April 8, 2025, the licensee was informed that a civil penalty might be assessed, based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by facility staff’s failure to seek timely medical treatment for Resident (R3), after R3 suffered an unwitnessed fall while in care, causing a fracture to R3’s left intertrochanteric femur, resulting in R3’s hospitalization and surgical cephallomedullary nail placement, followed by physical rehabilitation therapy. Today, September 17, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department determines constitutes as serious bodily injury, in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Lighthouse Director Jennifer Hinch and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 17, 2026

Allegation investigated: Staff did not prevent a resident from harrassing another resident. Staff restrained a resident. Staff accessed resident's apartment without permission.

On 9/10/2026, 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** Unfounded Staff did not prevent a resident from harassing another resident. Based on interviews, record review, and observation, R3 expressed concerns regarding another resident eating in the facility’s designated dining area. Title 22 provides residents with the right to utilize the facility’s designated dining area. The other residents’ presence and use of the dining area did not constitute harassment. Residents cannot dictate where other residents exercise the right to dine within the facility or characterize the exercise of that right as harassment. Staff were not identified as failing to intervene in any conduct that constituted harassment. Therefore, this allegation is UNFOUNDED. Staff restrained a resident. Based on interviews, record reviews, and observation, there was no evidence that staff physically restrained R3, restricted R3’s freedom of movement, or prevented R3 from leaving against R3’s will. R3 stated that R3 was able to disengage from the encounter and leave when R3 chose to do so. Therefore, this allegation is UNFOUNDED. Staff accessed resident's apartment without permission. Based on interviews, record review, and observation, R3 stated that staff do not enter R3’s apartment except on scheduled cleaning days. R3 identified Wednesdays as the scheduled cleaning day and stated that staff enter the apartment with R3’s permission to provide cleaning services. There was no evidence that staff entered R3’s apartment outside of scheduled cleaning services or without R3’s permission. Therefore, this allegation is UNFOUNDED. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Sep 10, 2026 · control 59-AS-20260805121219

Allegation investigated: Staff did not prevent a resident from physically assaulting another resident in care

On 04/27/2026, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Assisted Living Director Jennifer Hinch. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: The Department conducted interviews and reviewed facility records including incident reports and care and supervision documentation. The investigation confirmed that a resident-to-resident altercation occurred; however, evidence did not establish that staff failed to provide appropriate supervision or that staff actions or inactions contributed to the incident. Available information indicates staff responded consistent with facility policies and intervened upon awareness of the incident. Although the incident occured, the preponderance of evidence does not support a finding that staff failed to prevent assault. Therefore, the allegation is determined to be UNSUBSTANTIATED. Exit interview conducted. Report left with facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 27, 2026 · control 59-AS-20260130142011

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lavinia Muscan arrived on 12/16/2025 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed ten resident (10) and ten staff (10) files. All residents files contained the required paperwork. All staff files contained the required paperwork and training. LPA, Administrator Landon Pilegaard, and Assisted Living Director Jennifer Hinch toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, kitchen, hallways, memory care apartments, memory care dining room/kitchen, and memory care common areas. Water temperatures in the apartments toured were within the required range of temperature. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to Administrator.the state’s words, verbatim · CDSS document, Dec 16, 2025

Type of visit: Office

On 06/10/25, around 01:30 PM, Licensing Program Manager (LPM) Troy Ordonez, Licensing Program Manager (LPM) Laura Munoz, Licensing Program Analyst (LPA) Talwinder Bains, Licensing Program Analyst (LPA) Lavinia Muscan were present for a Non-compliance Conference with Licensee Erik Pilegaard, Administrator Landon Pilegaard and Managing Director Terry Howard, which was held in-person in the office. This conference does not in any manner excuse past problems or resolve the Department’s case against the licensee if the problems are not corrected. The Non-Compliance Conference may be the last step prior to initiating administrative action following unsuccessful attempts by the Department to gain compliance. Since 2021, the facility has been issued 2 A citations, 1 B citation and assessed 1 civil penalty in the amount of $500. (1) open complaints and (1) outstanding appeal. We did receive your appeal for the citations issued on April 8, 2025 which is currently under review. Substantiated Complaints include allegations in the following areas: - Timely medical -Observation of resident - Four separate incidents involving serious resident injuries and one death The licensee shall submit the following: Training, policies, management oversight, ensuring care staff is aware and familiar with the needs of the residents they provide care for and when to call 911. Develop and implement new protocols for timely medical response; supervision and fall reduction; conducting mandatory training for all staff in the above areas. Implement internal audits and increased administrative oversight. Compliance plan documents shall be submitted to CCL by: 6/17/25 COB; Fully implement plan with documentation by 7/10/25. Provide proof of staff training completion. Submit all documents to lavinia.muscan@dss.ca.gov. The licensee agreed with the drafted non-compliance plan as outlined in LIC 9111. No citations were issued today. An exit interview was conducted, and a copy of this report was provided to the licensee.the state’s words, verbatim · CDSS document, Jun 10, 2025

Allegation investigated: Staff sexually abused residents while in care. Facility does not have adequate staffing to meet residents' needs.

On June 9, 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 Staff sexually abused residents while in care. During the course of the investigation, R1’s details of the incident was inconsistent. Based on R1’s medical records, R1 has diminished mental functions including dementia and schizoaffective disorder. The Sheriff’s Office conducted an investigation and were unable to substantiate the allegation based on lack of evidence and inconsistent statements made by R1. Additionally, the descriptions R1 provided of the suspect were inconsistent. Based on interviews conducted and records reviewed, there is insufficient evidence that staff sexually abused residents while in care. Facility does not have adequate staffing to meet residents' needs. Based on three (3) staff interviews, three (3) resident interviews, and record review, department was able to determine that there is adequate staffing to meet resident’s needs. Staff and residents were asked if there is adequate staffing. Nearly all persons said that there is adequate staffing and that all resident care needs are being met. Staff and residents could not provide a list of resident needs that were not provided or being met. Based upon the information obtained during investigation, the above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations 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.the state’s words, verbatim · CDSS document, Jun 9, 2025 · control 59-AS-20250317144735

Allegation investigated: 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.

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 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 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 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 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 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.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 59-AS-20240828164917

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 9, 2025

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. 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.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Apr 9, 2025

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). 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.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: 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.

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

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 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. 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.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 59-AS-20241105091005

Allegation investigated: Staff did not provide medications to resident as prescribed.

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 Staff did not provide medications to resident as prescribed. Based on documents obtained and statements reviewed for January 2025, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Five staff interviews (5) indicated that staff were not aware of any medication errors. Five resident interviews (5) expressed no concerns with medication administration. 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. Staff did not ensure resident's hygiene needs are being met. Staff does not ensure resident's dressing needs are being met. Staff does not ensure resident's rooms are cleaned and sanitized. Staff does not ensure resident's laundry needs are being met. Department conducted record review, staff, and resident interviews to investigate this allegation. Five (5) staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours or as needed. Five (5) resident interviews reflected that their care needs were met by staff and there were no issues to address. Based on five staff interviews (5) and five resident interviews (5) and department observation, the department observed the facility to be clean and sanitary. During department visits on 1/13/25 and 2/5/25 the department did not observe any unmet laundry needs. The facility did not observe to be malodorous including resident rooms, common areas and restrooms. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without and concerns; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegations are false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 59-AS-20250110132634

Allegation investigated: Staff did not ensure resident was kept clean Staff did not provide adequate food service to resident in care Staff did not treat resident with respect

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** Unfounded Staff did not ensure resident was kept clean Staff did not provide adequate food service to resident in care Department conducted record review, staff, and resident interviews to investigate this allegation. Five (5) staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours or as needed. Five (5) resident interviews reflected that their care needs were met by staff and there were no issues to address. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff meet their needs. Residents stated they have not had issues with food service including temperature of food, quality and quantity of the food served. Staff interviews indicated that the facility is kept clean and sanitary without and concerns; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegations are false, could not have happened and/or is without a reasonable basis. Staff did not treat resident with respect Department conducted staff and resident interviews to investigate this allegation. Five (5) staff interviews and five (5) resident interviews indicated that staff treat residents with respect. Resident interviews indicated that they have never witnessed or experienced abuse in the care home and that staff treat them with respect. Interviews with staff indicated that they have not witnessed anyone treat residents disrespectfully; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegations are false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 59-AS-20241224131204

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived on 2/5/2025 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed ten resident (10) and ten staff (10) files. All residents files contained the required paperwork. All staff files contained the required paperwork and training. LPA and Assisted Living Director Jennifer Hinch toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, kitchen, hallways, memory care apartments, memory care dining room/kitchen, and memory care common areas. Water temperatures in the apartments toured were within the required range of temperature. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to Staff.the state’s words, verbatim · CDSS document, Feb 5, 2025

Allegation investigated: Staff did not ensure resident wound care needs were met

On 10/1/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegation 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:Based on interviews, record reviewed and observation it was determined that the facility is meeting residents’ hygiene needs, including first aid and wound care, based on the residents needs and service plan. The facility uses correct bandages according to First Aid training. Department toured the facility on 7/29/24 and 9/25/24 and did not find any concerns. Two (2) resident interviews stated the caregivers/staff clean the facility and take care of their first aid needs, as needed, using correct bandages, no feminine products. Additionally, seven (7) staff and two (2) resident interviews did not indicate any issues at the facility with cleanliness, sanitation, and first aid and wound care. Based on all this information, the allegation is 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2024 · control 59-AS-20240725150447

Allegation investigated: Staff neglect resulted in a resident to be hospitalized Staff left a resident unattended

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 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. 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.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 59-AS-20240521225759

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Sep 13, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Lavinia Muscan arrived on 2/6/2024 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (15) and staff (10) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA and Administrator Landon Pilegaard toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, kitchen, hallways, memory care apartments, memory care dining room/kitchen, and memory care common areas. Water temperatures in the apartments toured were within the required range of temperature. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to Administrator.the state’s words, verbatim · CDSS document, Feb 6, 2024

Allegation investigated: Facility staff do not ensure residents’ hygiene needs are being met.

On 01/04/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to do complaint investigation and to deliver complaint findings into the allegation listed above and met with Administrator Landon Pilegaard . During the investigation, the Department conducted interviews with 3 staff and 2 residents and reviewed documentation pertinent to the investigation. Staff and residents interviews indicated that residents hygiene needs are met per residents needs and service plan. Staff interiews indicated that memory care staff does not cut residents nails per facility policy and nails care are done for residents by thier families or salon. For hospice residents, it is done by hospice company. Memory care staff clean residents nails as needed. 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 was conducted with Administrator and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 4, 2024 · control 59-AS-20231226152933

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged residents' medication

On 10/30/23, 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: Staff mismanaged residents' medication. - UNSUBSTANIATED Based on documents obtained and statements received, the department determined that there was insufficient evidence that any resident’s medication was mismanaged. RP stated that the facility was mishandling resident medications; however, RP was unable to provide any dates, names, or type of medication that was being mishandled. Documents obtained show that all current medications were administered and logged correctly. 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 was conducted with Administrator and a copy of this report was provided to the facility. Unsubstantiated Staff neglected residents while in care .-UNFOUNDED Staff did not provide a safe and comfortable environment for residents. -UNFOUNDED Based on records reviewed, interviews, and department observations on 9/19/23 and 10/18/23, LPA observed that the staff meeting residents’ needs and provided a safe and comfortable environment for all residents in care. Furthermore, interviews with residents indicated that staff were providing care to residents per their care and service plans and were not neglecting residents care needs. Therefore, the allegation that residents are neglected while in care and not staff did not provide a safe and comfortable environment for residents is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff inappropriately transported deceased resident .- UNFOUNDED Based on records reviewed and interviews conducted by department on 09/19/23 and 10/18/23, the department did not find any evidence that staff inappropriately transported a deceased resident. Based on interviews it has been determined that only the mortician transports the deceased residents and that the staff only help if they are asked therefore the allegation staff inappropriately transported deceased resident 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 was conducted with Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 59-AS-20230912091436

Allegation investigated: Staff did not prevent resident from being injured by another resident Staff did not provide written incident report to resident's responsible party within 7 days Staff do not assist resident with incontinence needs

On 10/11/23, 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** Unfounded Staff did not prevent resident from being injured by another resident. Based on interviews conducted with staff and with residents on 8/9/23 and 9/12/23. On 7/19/23 an incident was reported that a resident was moving in their wheelchair and accidentally grazed R1 on the leg. R1 sustained a bruise, however, did not sustain any additional injuries. Although R1 was injured by a resident’s wheelchair, the incident was an accident and did not occur again therefore the allegation is 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 provide written incident report to resident's responsible party within 7 days Based on records reviewed and interviews it was determined that staff notified R1’s responsible party of an incident that occurred at the facility on 7/19/23, the same day the incident occurred. Upon review, it was also found that the facility notified the Department of the incident on 7/26/23 within 7 days per Title 22 requirements. Therefore, this allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff do not assist resident with incontinence needs Regarding the allegation that staff do not assist residents with incontinence care, LPA met with several residents, spoke with several staff, and reviewed documentation. LPA learned that residents are checked regularly, at least every couple of hours, and staff assist residents with continence and incontinence per needs and service plans. Staff are aware of those residents who may need more frequent or extra assistance and monitor them. At this time, residents are changed when needed based on their needs and service plan. Therefore, the 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. Copy of report left at facility.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230803115533