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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001275
Report Date: 03/29/2021
Date Signed: 03/29/2021 12:27:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ESKATON LODGE CAMERON PARKFACILITY NUMBER:
097001275
ADMINISTRATOR:TOPPING, MARNAFACILITY TYPE:
740
ADDRESS:3421 PALMER DRTELEPHONE:
(530) 672-8900
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:60CENSUS: 26DATE:
03/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marna ToppingTIME COMPLETED:
12:30 PM
NARRATIVE
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Case Management visit regarding an incident on 2/23/21 where CN #1 (staff) was observed kissing CN #2 (resident). El Dorado County Sheriff PR# EG 21-1635.

See 809-D for deficiency cited.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ESKATON LODGE CAMERON PARK
FACILITY NUMBER: 097001275
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/29/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities - Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on witnesses, staff member CN #1 violated the
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personal rights of CN #2 when he was observed kissing identified resident. This is in violation of this section. This 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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2