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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 095920187
Report Date: 04/28/2026
Date Signed: 04/28/2026 03:47:56 PM

Unsubstantiated


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
03/10/2026 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20260310163302
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: 64DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Kim DelgadoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Due to staff neglect, resident sustained pressure injuries
INVESTIGATION FINDINGS:
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On 4/28/2026, Licensing Program Analyst (LPA) Lavinia Muscan 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**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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
Control Number 59-AS-20260310163302
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: 04/28/2026
NARRATIVE
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Due to staff neglect, resident sustained pressure injuries
Review of records and interviews indicates that R1 was receiving ongoing medical oversight from multiple external providers while residing in the facility. R1 was on home health services that visited the facility three times per week to provide skilled nursing care, including wound management. In addition, R1 received consistent wound care services through InnovAge on Fridays, where the wound was being actively monitored and treated by licensed nursing staff. Documentation indicates R1’s care needs were being addressed through coordinated medical services outside the facility staff. R1 was later admitted on hospice care after being enrolled through home health services beginning 02/20/2026. Based on the information obtained, there is insufficient evidence to demonstrate that facility staff did not provide care and supervision in accordance with Title 22, or that any action or inaction by facility staff directly resulted in or contributed to the development or worsening of R1’s injuries. Therefore, the allegation is determined to be UNSUBSTANTIATED.

Exit interview conducted. Report left with facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2