<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297001933
Report Date: 03/19/2024
Date Signed: 03/19/2024 04:44:28 PM


Document Has Been Signed on 03/19/2024 04:44 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 GRASS VALLEYFACILITY NUMBER:
297001933
ADMINISTRATOR:ALICIA RISTFACILITY TYPE:
740
ADDRESS:625 ESKATON CIRTELEPHONE:
(530) 273-1778
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:160CENSUS: 131DATE:
03/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Alicia Rist, Executive DirectorTIME COMPLETED:
12:30 PM
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
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Alicia Rist, to conduct a case management visit regarding incident reports received by the Department.

An Unusual Incident/Injury Report (SIR) was completed for an incident that occurred on 3/1/2024, in which a resident lost their wallet. Interview with ED indicated that the facility checked the entire Memory Care Unit (MCU) and spoke with the resident's family. Family report that a bank card was lost but didn't have activity on the card. Facility recommended to cancel the card. A police report was filed regarding the incident. As of today's date, the wallet has yet to be relocated. Facility will follow-up on the status of the lost wallet with resident's family.

The Department received SIRs for falls dated 11/10/2023, 12/28/2023, 1/3/2024. LPA followed up regarding each residents' history will falls and the preventative measures made on behave of the facility to address falls.

LPA followed-up regarding a resident-on-resident altercation dated 2/17/2024. Two residents had a physical altercation in the dining room and had already separated before staff could intervene. There were no injuries reported regarding incident. Resident and residents' families were consulted with the facility's house rules and no other altercations have been reported.

As a result of today's visit, no deficiencies are being cited. LPA will conduct a visit to follow-up regarding incidents if the Department deems necessary.

Exit interview was conducted with ED and a copy of this report was provided to the facility. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1