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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 03:17:44 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
08/19/2026 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20260819115901
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:
02:30 PM
MET WITH:Health Services Manager Carla LambertTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff did not ensure that resident did not have contact with harmful chemicals.
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 Health Services Manager Carla Lambert.
During investigation, it was learned that staff use Home Defense Insect Killer to address the facility ant problem. The department observed documentation that showed a bottle of the insect killer was left in a resident’s room who as a diagnosis of dementia. Additionally, department staff found multiple ant bait stations in R1’s room accessible to residents in care. Based on documentation, ant bait stations could have toxicity to humans. R1 has a diagnosis of Dementia. Based on the information obtained, the facility did not ensure poisonous chemicals are kept inaccessible to residents in care 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-20260819115901
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(a)(1)
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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.(1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This was not met as evidenced by ...
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HSM agrees to check with maintenance to make sure both HSM and maintenance signs off for apartments treated and chemicals stored and put away. HSM agrees to send in a statement of understanding of this regulation. POC due date 8/26/26.
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During investigation, it was learned that staff use Home Defense Insect Killer to address the facility ant problem. The department observed documentation that showed a bottle of the insect killer was left in a resident’s room who as a diagnosis of dementia. Additionally, department staff found multiple ant bait stations in R1’s room accessible to residents in care. Based on documentation, ant bait stations could have toxicity to humans. R1 has a diagnosis of Dementia, 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)
Page: 2 of 2