297001933-6-4-2025-59-AS-KHOS-DHQH2C-20250617054832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 297001933
Report Date: 06/04/2025
Date Signed: 06/04/2025 03:18:31 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2025 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20250530091642

FACILITY NAME:	ESKATON VILLAGE GRASS VALLEY		FACILITY NUMBER:	297001933
ADMINISTRATOR:	ALICIA RIST		FACILITY TYPE:	740
ADDRESS:	625 ESKATON CIR		TELEPHONE:	(530) 273-1778
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	160	CENSUS: 126	DATE:	06/04/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Sydney Lawson, Business Services Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not follow the residents hospice care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Business Services Manager (BSM), Sydney Lawson, to open a complaint investigation into the allegation listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Staff did not follow the residents hospice care plan

** Report continued on 9099-C **

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250530091642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VALLEY	FACILITY NUMBER: 297001933
	VISIT DATE: 06/04/2025

NARRATIVE

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LPA conducted interviews with multiple representatives of resident (R1's) hospice agency, which indicated that they had no concerns regarding neglect on behalf of the facility. Interviews with hospice representatives indicated no concerns regarding the facility following R1's hospice care plan. LPA reviewed R1's Agency Discharge Summary with hospice representative, who indicated that the care plan was met by the facility.

Interviews with Resident Care Director (RCD), Becca Deges, and Executive Director (ED), Alicia Rist, indicated that R1 was checked every two (2) hours. ED, RCD, and hospice representative stated that R1 had sometimes refused to use pendant. ED, RCD, and hospice representative indicated that R1 had their pendant with them on May 14, 2025 when they were found on the floor. ED, RCD, and hospice representative indicated that R1 had not used their pendant regarding fall. ED, RCD, and hospice representative indicated that staff had checked on R1 an hour prior to R1's fall on May 14, 2025.

Based on interviews conducted and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC9099 (FAS) - (06/04)

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