Ponte Palmero.

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.

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.

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.

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. 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 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.

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.

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. 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 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.

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.

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.

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.

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.