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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297001933
Report Date: 06/02/2021
Date Signed: 07/08/2021 04:36:32 PM

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 GRASS VALLEYFACILITY NUMBER:
297001933
ADMINISTRATOR:HILL, ADAMFACILITY TYPE:
740
ADDRESS:625 ESKATON CIRTELEPHONE:
(530) 273-1778
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:160CENSUS: 120DATE:
06/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sean BeloudTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA)s Williams and Keosavang arrived at the facility unannounced on 06/2/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPAs met with Administrator, Sean Beloud, and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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 and contacted licensee and completed a facility risk assessment. LPAs ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPAs was screened by facility staff upon entering the facility.

LPAs and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, seven (7) resident bedrooms, numerous restrooms, kitchen, and courtyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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