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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 297001933
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:58:06 PM

Unfounded


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
12/28/2021 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20211228132044
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:
06/16/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cameron Uhlir, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility's Emergency Disaster Plan is not sufficient
INVESTIGATION FINDINGS:
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On 6/16/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Cameron Uhlir, to conclude a complaint investigation into the allegations listed above. LPA wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises.

During the investigation, the Department reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility's Emergency Disaster Plan is not sufficient

** Report continued on 9099-C **
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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 2
Control Number 25-AS-20211228132044
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: 06/16/2022
NARRATIVE
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During inspection conducted on 6/16/2022, LPA Hood reviewed the facility's Emergency Disaster Plan for Residential Care Facilities for the Elderly (LIC 610 E). LPA determined Emergency Disaster Plan to be sufficient in relation to Title 22 regulations.

Based on 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 with ED and a copy of this report was provided to the facility. The signature of the ED 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: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2