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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 095920187
Report Date: 08/25/2026
Date Signed: 08/25/2026 03:52:50 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
08/18/2026 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20260818094110
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: 59DATE:
08/25/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:HSM Carla LambertTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not ensure residents' bedding is free from ants
Staff do not ensure residents' clothing is free from ants
Staff do not ensure residents' incontinence briefs are free from ants
INVESTIGATION FINDINGS:
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On August 25, 2026, Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to open complaint regarding the allegations listed above and met with HSM Carla Lambert.
During the investigation, department staff observed live and dead ants on multiple residents’ bedding and disposable bed pads. Interviews with staff indicated the ant problem as been an ongoing issue. Based on observations, the facility did not ensure residents’ bedding was free of ants therefore the allegation is SUBSTANTIATED. During the investigation, department staff observed live ants crawling on multiple residents’ clothing. Additionally, photos were provided during the course of the investigation that shows ants present on a resident’s brief. It should be noted that the photo of the resident is one of the resident’s beds that were observed with live and dead ants on their bedding. Based on observations, the facility did not ensure residents’ persons free of ants therefore the allegation is SUBSTANTIATED.

Exit Interview conducted. Appeal rights and report left with facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026
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 2
Citations on this Visit Report are Under Appeal!

Control Number 59-AS-20260818094110
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: 08/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/26/2026
Section Cited
CCR
87309(3)(c)
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87309 Storage Space and Access
(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. This was not met as evidenced by ...
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HSM agrees to check each sheet that there are no ants on each shift and clear directions on what to do if there are ants in the room. Clean and disinfect apartment daily. HSM agrees to send in a statement of understanding of this regulation. Also, have pest control come out to do an inspection. POC due date 8/26/26.
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During the investigation, department staff observed live and dead ants on multiple residents’ bedding and disposable bed pads. Interviews with staff indicated the ant problem as been an ongoing issue, which possess an immediate health and safety hazard to residents in care.
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Under Appeal
Type A
08/25/2026
Section Cited
CCR
87468.1(a)(2)
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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: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by ...
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HSM agrees to check in on residents and train staff to accord safe and comfortable accomodations for residents in care. HSM agrees to send in a statement of understanding of this regulation. POC due date 8/26/26.
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During the investigation, department staff observed live ants crawling on multiple residents’ clothing. Additionally, photos were provided during the course of the investigation that shows ants present on a resident’s brief. It should be noted that the photo of the resident is one of the resident’s beds that were observed with live and dead ants on their bedding, which poses an immediate health and safety risk to residents in care. .
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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 Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026
LIC9099 (FAS) - (06/04)
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