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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005046
Report Date: 08/11/2021
Date Signed: 08/11/2021 11:33:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 47DATE:
08/11/2021
TYPE OF VISIT:Case Management - Health ChecksANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Evelyn McGrath, AdministratorTIME COMPLETED:
11:30 AM
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On 08/11/2021, Licensing Program Analyst (LPA) Michael Hood, conducted an in-person health and safety check visit due to a COVID-19 outbreak and met with Administrator, Evelyn McGrath, Infection Preventionist Kristy Trausch, and El Dorado County Public Health Nurse Nate Deardorff. Prior to initiating the visit, LPA completed required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask and goggles.

LPA toured the facility inside, including but not limited to the hallways, facility dining area, and common areas, for both the Assisted Living and Memory Care units. LPA observed residents' care needs were being met. LPA observed facility staff wearing N95s, including designated staff caring for COVID-19 positive residents. LPA observed sufficient PPE supplies and staffing at the facility.

Infection Preventionist recommended the following during visit:
· Add vaccine question to screening process in kiosk
· Contact hospital whenever a COVID-19 positive resident or resident experiencing COVID-19 related symptoms is being transferred to the hospital

Infection Preventionist did not express any concerns regarding facility’s COVID-19 precautionary measures at conclusion of visit.

No deficiencies are being cited as a result of today's visit. Exit interview was conducted with Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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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