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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005046
Report Date: 09/24/2020
Date Signed: 09/24/2020 04:14:45 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 VILLAGE PLACERVILLEFACILITY NUMBER:
097005046
ADMINISTRATOR:MCGRATH, EVELYNFACILITY TYPE:
740
ADDRESS:3380 BLAIRS LNTELEPHONE:
(530) 295-3400
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:74CENSUS: 60DATE:
09/24/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Evelyn McGrath, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Michael Hood spoke with Administrator, Evelyn McGrath, via telephone to conduct a case management visit. Today's visit was conducted by telephone due to COVID-19 and precautionary measures. The purpose of today's visit was to follow-up on a death report that was received by the Department.

On 9/21/2020, R1 was found unresponsive in their bed by care staff. CPR was administered by care staff and paramedics were called into facility. Paramedics pronounced R1 dead at the facility. Death report indicates death as unexpected.

During today's telephone visit, LPA interviewed Administrator and requested documentation pertinent to R1's care to be emailed to LPA.

At this time, deficiencies are not being cited. A copy of this report has been emailed to the facility and the Administrator was advised that a signed copy of the report shall be submitted to CCLD within 10 days of receipt of this report.

Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2020
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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