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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097005046
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:09:18 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
05/08/2024 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20240508113749
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: 49DATE:
08/05/2024
UNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Administrator Melisa TiburcioTIME COMPLETED:
03:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff violated resident’s personal rights by not allowing her to leave facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/5/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Melisa Tiburcio.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows:
Through the course of the investigation process, CCL conducted interviews, toured the facility, and reviewed records regarding the allegation above. During the investigation, it was determined that the care provider was trying to provide care and supervision to R1 based on the resident's needs and restraining order documents on file. The facility responded based on the most current documents they were provided. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

Exit interview conducted and copy of report provided to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
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
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
05/08/2024 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20240508113749

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: 49DATE:
08/05/2024
UNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Administrator Melisa TiburcioTIME COMPLETED:
03:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident’s personal belongings are missing
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/5/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Melisa Tiburcio.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows:
Through the course of the investigation process, CCL conducted interviews, toured the facility, and reviewed records regarding the allegation above. During the investigation, it was determined that R1 misplaced R1’s personal belongings and were found later, therefore the allegation is Unfounded. This agency has investigated this complaint. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and copy of report provided to Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2