<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 095920187
Report Date: 08/11/2026
Date Signed: 08/11/2026 03:49:40 PM

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
04/03/2026 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20260403145712
FACILITY NAME:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
095920187
ADMINISTRATOR:DELGADO, KIMBERLYFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:64CENSUS: 61DATE:
08/11/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Kim DelgadoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect led to resident's hospitalization.
Staff did not ensure resident's hygiene needs were met while in care.
Staff did nof ensure that resident's toileting needs were met while in care.
Staff did not address resident's change in condition while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/11/2026, 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 Kim Delgado.

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:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
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 5
Control Number 59-AS-20260403145712
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: PAVILION AT EL DORADO HILLS, THE
FACILITY NUMBER: 095920187
VISIT DATE: 08/11/2026
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
Facility neglect led to resident hospitalization.
Staff did not address resident's change in condition while in care.
Based on interviews, record reviews, and other evidence obtained during the investigation, the resident had a documented history of diabetes and required blood glucose monitoring. Facility records reflected a blood glucose level of 290 mg/dL on 2/4/26 (PM), 133 mg/dL on 2/5/26 (AM), 66 mg/dL on 2/6/26 (AM), and a critically low blood glucose level of 44 mg/dL on 2/7/26 at approximately 8:00 a.m. Scheduled PM blood glucose readings on 2/5/26 and 2/6/26 were not documented. The medication technician documented the resident’s blood glucose at 44 mg/dL on 2/7/26 and administered the ordered intervention. However, facility records contained no documentation that the resident’s blood glucose was reassessed following the intervention to determine its effectiveness. Approximately seven hours elapsed without documented follow-up monitoring despite the critically low blood glucose level. At approximately 3:00 p.m. on 2/7/26, the resident was found clammy and unresponsive. The residents’ blood pressure was documented as 55/29, oxygen saturation as 74%, and pulse as 95. Emergency medical services were contacted, and the resident was transported to the hospital, where the resident was diagnosed with a urinary tract infection resulting in sepsis. The investigation determined the facility failed to adequately monitor and reassess the resident following a critically low blood glucose reading and failed to recognize and respond to the resident’s significant change in condition in a timely manner. These failures contributed to the progression of the resident’s deteriorating condition and the need for hospitalization.
According to the incident report, R1 was found unresponsive on 02/07/2026 and hospitalized with septic shock due to an E. coli UTI and bacteremia. Staff reported they were unaware of R1's history of UTIs and did not observe a change in condition.
Caregivers reported residents were generally checked or changed only two to three times per eight-hour shift due to workload. The Health Services Manager acknowledged R1's known UTI risk factors were not addressed and accepted responsibility, while the Executive Director also acknowledged responsibility and the need for additional staff training.

Continue on page 2 ...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20260403145712
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: PAVILION AT EL DORADO HILLS, THE
FACILITY NUMBER: 095920187
VISIT DATE: 08/11/2026
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
Facility staff failed to meet the residents’ toileting needs.
Based on interviews, record reviews, and other evidence obtained during the investigation, the facility’s Plan of Operation requires incontinent residents to be checked and provided with incontinent care at a minimum of every two hours, including overnight. Staff interviews consistently revealed this expectation was not being met. Multiple staff members stated it was not possible to provide incontinent care every two hours because of staffing limitations and resident need. Staff consistently reported that incontinent residents were generally changed only two to three times during an eight-hour shift rather than every two hours as required by the facility’s own procedures. Documentation reviewed during the investigation did not demonstrate residents consistently received incontinent care at the frequency required by the facility’s Plan of Operation. The investigation further determined staffing practices prevented staff from consistently providing timely toileting assistance and incontinent care. The resident was subsequently hospitalized and diagnosed with a urinary tract infection resulting in sepsis. The Department determined the facility failed to ensure the residents’ toileting and incontinent care needs were consistently met.

Facility staff failed to meet the residents’ hygiene needs.
Based on interviews, record reviews, and other evidence obtained during the investigation, the facility’s Plan of Operation requires staff to routinely monitor residents and provide hygiene and incontinent care at least every two hours. Interviews conducted during the investigation established staff were unable to consistently comply with this requirement due to staffing limitations. Staff acknowledged residents frequently remained in soiled briefs for extended periods because staff were responsible for more residents than they could appropriately care for during a shift. The investigation determined the facility failed to ensure staff consistently provided hygiene and personal care services necessary to maintain residents in a clean, dry, and comfortable condition as required by the facility’s own policies and applicable regulations.

The preponderance of evidence standards has been met. 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. Immediate civil penalty of $500.00 was issued today. Failure to correct shall result in civil penalties.

Exit interview conducted. Appeal Rights given to administrator. A copy of this report has been provided to facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Citations on this Visit Report are Under Appeal!

Control Number 59-AS-20260403145712
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: PAVILION AT EL DORADO HILLS, THE
FACILITY NUMBER: 095920187
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2026
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. This requirement was not met as evidenced by ...
1
2
3
4
5
6
7
Administrator will send a letter of understanding of this regulation and will conduct staff training. Facility will submit a plan on how facility will ensure residents change in condition is being monitored. All POC documents are dues by 8/12/26.
8
9
10
11
12
13
14
Staff did not recognize and respond promptly to resident’s declining condition, including signs and symptoms requiring medical intervention. As a result, the resident’s condition deteriorated and required hospitalization which possess an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Under Appeal
Type A
08/12/2026
Section Cited
CCR
87208(a)
1
2
3
4
5
6
7
Plan of Operation - The licensee failed to operate the facility in accordance with its approved Plan of Operation. This requirement was not met as evidenced by ...
1
2
3
4
5
6
7
Administrator will send a letter of understanding of this regulation and will conduct staff training. Facility will submit a plan on how facility will ensure residents are changed according to the facility Plan of Operation, which is every 2 hours including at night. All POC documents are dues by 8/12/26.
8
9
10
11
12
13
14
Specifically, the facility’s Plan of Operation required incontinent residents to be checked and provided with incontinent care at least every two hours. Evidence obtained during the investigation demonstrated that residents were not consistently provided care in accordance with the Plan of Operation which poses 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
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
04/03/2026 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20260403145712

FACILITY NAME:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
095920187
ADMINISTRATOR:DELGADO, KIMBERLYFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE:CAZIP CODE:
95762
CAPACITY:64CENSUS: DATE:
08/11/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Kim DelgadoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff overmedicated resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/11/2026, 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 Kim Delgado. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:
Based on a review of facility records, including the physician’s orders and medication administration records (MARs), the facility administered the resident’s medication as prescribed by the resident’s physician. Documentation supported that the increase in medication was ordered by the physician and implemented in accordance with those orders. No evidence was found that facility staff administered medication more than, or inconsistent with, the physician’s prescribed dosage. Therefore, the allegation that staff over-medicated the resident 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5