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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005046
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:06:13 PM


Document Has Been Signed on 08/05/2024 03:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ESKATON VILLAGE PLACERVILLEFACILITY NUMBER:
097005046
ADMINISTRATOR:TIBURCIO, MELISAFACILITY TYPE:
740
ADDRESS:3380 BLAIRS LNTELEPHONE:
(530) 295-3400
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:74CENSUS: 49DATE:
08/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Melisa TiburcioTIME COMPLETED:
03:20 PM
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On 08/05/24, Licensing Program Analyst (LPA) Lavinia Muscan, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator Melisa Tiburcio and explained the purpose of the visit.

LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, hallways, common restrooms, and outside area. LPA observed the facility to be clean, in good repair and odor-free. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. The hot water temperature measured within the required range of 105-120 degrees. LPA observed facility's fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and five (6) staff files.

There were no deficiencies cited at this time.

An exit interview was held, and a copy of the report was provided to Administrator Melisa Tiburcio.

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.

LIC809 (FAS) - (06/04)
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