297001933-7-23-2021-27-AS-MSEY-C5BTEX-20210727144040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 297001933
Report Date: 07/23/2021
Date Signed: 07/23/2021 05:17:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2020 and conducted by Evaluator Pheej Cheng

COMPLAINT CONTROL NUMBER: 27-AS-20201001113808

FACILITY NAME:	ESKATON VILLAGE GRASS VALLEY		FACILITY NUMBER:	297001933
ADMINISTRATOR:	HILL, ADAM		FACILITY TYPE:	740
ADDRESS:	625 ESKATON CIR		TELEPHONE:	(530) 273-1778
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	160	CENSUS: 125	DATE:	07/23/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Monica Avalos; Resident Care Coordinator II		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1) Staff not providing meals to resident in a timely manner.
2) Staff not providing adequate food service for resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/16/2021 at 3PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation visit regarding the above allegation and Resident Care Coordinator II Monica Avalos. 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; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Additionally, LPA was screened by facility's automated temperature system and front desk personnel.

Continuation on LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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 3

Control Number 27-AS-20201001113808

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VALLEY	FACILITY NUMBER: 297001933
	VISIT DATE: 07/23/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

1) Staff not providing meals to resident in a timely manner.

Based on 10 staff and 12 resident interview statements obtained, LPA determined that the above allegation occurred. Four staff members interviewed confirmed that there were incidents of residents receiving their meals late or not at all during October 2020. Two residents confirmed to have received their meals late during this period.

2) Staff not providing adequate food service for resident.

Based on 10 staff and 12 resident interview statements obtained, LPA determined that the above allegation occurred. During this period, 4 staff members confirmed of burnt toast being served and 2 residents confirmed receiving burnt toast. 3 staff members did not visually witness burnt toast being served but doesn't doubt that that residents did receive burnt toast. 3 staff members confirmed that residents were served frozen or undercooked vegetables and 1 staff confirmed the allegation.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of the report was given.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20201001113808

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VALLEY	FACILITY NUMBER: 297001933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 08/02/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f)(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to conduct an in-service training regarding facility meal service procedures and submit training materials along with food service staff to LPA by POC date.
	8 9 10 11 12 13 14	Based on staff and resident interviews, Licensee did not provide meal services on time which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type B 08/02/2021 Section Cited CCR 87555(b)(8)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b)(8) All food shall be of good quality. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to conduct an in-service refresher course regarding ServSafe Food Handling requirements and submit training materials along with signatures of food service staff to LPA by POC date.
	8 9 10 11 12 13 14	Based on resident and staff interviews, Licensee did not ensure that fozen and/or undercooked food were not served to residents which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3