Facility Evaluation Report

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

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.