297001933-6-16-2022-25-AS-KHOS-CFLKT5-20220621081034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 297001933
Report Date: 06/16/2022
Date Signed: 06/16/2022 01:59:02 PM

Substantiated

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
12/29/2021 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20211229094428

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: 120	DATE:	06/16/2022
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Cameron Uhlir, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not supply heat to residents' bedrooms

INVESTIGATION FINDINGS:

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

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 allegation 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 conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility did not supply heat to residents' bedrooms

** Report continued on 9099-C **

Substantiated

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: 06/16/2022

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 8

Control Number 25-AS-20211229094428

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

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

During the investigative process, the administrator, eight staff persons, the Local Long-Term Care Ombudsman (LTCO), and three residents were interviewed. Numerous documents were obtained for review and included the facility's Emergency and Disaster Plan, Disaster Plan Summary, Floor Plan, Emergency Procedures, Food Services/Emergency Disaster Plan, Emergency Contact Numbers, and Sheltering in Place Procedures.

It was reported that, approximately sometime between 12/27/2021 and 12/29/2021, the facility could not provide electricity to the residents’ bedrooms due to a snowstorm.

The facility has written in their Sheltering In Place Procedures the following statement: “In case of outage EVGV (Eskaton Village Grass Valley) has a generator that will power common areas, kitchen & hallways. EVGV has an emergency supply closet stocked with water, blankets, lanterns and batteries located in storage behind main elevator. The individual rooms will not have Heat/AC so we can open apartment doors to circulate air into each room. Residents will be asked to stay in their rooms and staff would perform regular well-being checks. Meals would be delivered to the room (in-room dining) as well as activities and engagement opportunities.”

The Emergency Power Sources document states in part “Resident Hallways/Corridors will be powered with lights and central air. EVGV has three (3) portable battery powered generators sources on site.” (...) “Care staff will have previously identified those residents that require assistance with Portable Oxygen. These individuals will be directed to a designated area or staff will supply temporary power for this period of this event.”

The Call System Failure or Power Outage document states “When power is out for an extended period of time and residents are unable to use our Call System (Arial) for help we need to immediately: Provide each resident with a whistle/bell. The whistles/bells are located with evacuation supplies. Care staff will implement wellness checks on each resident at a minimum of every hour.”

During the interview process, it was reported by staff that some residents were cold due to not having heat directly in the residents' bedrooms. It was stated that blankets were provided to the residents in an effort to assist the residents with staying warm.
** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 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 8

Control Number 25-AS-20211229094428

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

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

It was reported by the administrative staff that it was felt that the residual heat coming from the hallways into the residents' open bedroom doors would suffice to heat the resident bedrooms. The regulations state that a comfortable temperature for the residents shall be maintained at all times and that the facility shall heat rooms that residents occupy to a minimum of 68-degrees F. During a significant power outage, it was reported that no one monitored the temperature in the residents’ bedrooms to ensure that the rooms were at a comfortable temperature and at a minimum of 68-degrees F.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. The ED’s 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: 06/16/2022

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: 3 of 8

Control Number 25-AS-20211229094428

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: 06/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/08/2022 Section Cited CCR 87303(b)(1)	1 2 3 4 5 6 7	87303(b)(1) Maintenance and Operation - (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68-degrees F, (20 degrees C). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ED will develop a plan in writing on how the facility will avoid the complaint allegation from reoccurring. ED will submit plan to the Department by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure that resident bedrooms were at a comfortable temperature and at a minimum of 68-degrees F., which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 8

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
12/29/2021 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20211229094428

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: 120	DATE:	06/16/2022
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Cameron Uhlir, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not supply light to residents' bedrooms

Facility did not have staff to serve meals to residents

INVESTIGATION FINDINGS:

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

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 toured the facility, conducted interviews, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility did not supply light to residents' bedrooms

** Report continued on 9099-C **

Unsubstantiated

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: 06/16/2022

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: 5 of 8

Control Number 25-AS-20211229094428

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

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

During the investigative process, the administrator, eight staff persons, the Local Long-Term Care Ombudsman (LTCO), and three residents were interviewed. Numerous documents were obtained for review and included the facility's Emergency and Disaster Plan, Disaster Plan Summary, Floor Plan, Emergency Procedures, Food Services/Emergency Disaster Plan, Emergency Contact Numbers, and Sheltering in Place Procedures.

It was reported that, approximately sometime between 12/27/2021 and 12/29/2021, the facility could not provide electricity to the residents’ bedrooms due to a snowstorm.

The facility has written in their Sheltering In Place Procedures the following statement:
“In case of outage EVGV (Eskaton Village Grass Valley) has a generator that will power common areas, kitchen & hallways. EVGV has an emergency supply closet stocked with water, blankets, lanterns and batteries located in storage behind main elevator. The individual rooms will not have Heat/AC so we can open apartment doors to circulate air into each room. Residents will be asked to stay in their rooms and staff would perform regular well-being checks. Meals would be delivered to the room (in-room dining) as well as activities and engagement opportunities.”

The Emergency Power Sources document states in part “Resident Hallways/Corridors will be powered with lights and central air. EVGV has three (3) portable battery powered generators sources on site.” (...) “Care staff will have previously identified those residents that require assistance with Portable Oxygen. These individuals will be directed to a designated area or staff will supply temporary power for this period of this event.”

The Call System Failure or Power Outage document states “When power is out for an extended period of time and residents are unable to use our Call System (Arial) for help we need to immediately: Provide each resident with a whistle/bell. The whistles/bells are located with evacuation supplies. Care staff will implement wellness checks on each resident at a minimum of every hour.”

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 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: 6 of 8

Control Number 25-AS-20211229094428

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

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

During the interview process, it was reported by staff that, due to the power outage, the residents did not have electrical lighting in their bedrooms. It was reported that lighting was in the hallway and that doors were left open to receive light from the hallways. It was stated that residents were provided with a small battery operated lantern for their bedroom. Staff reported that most activities of daily living for the residents were provided. It was also mentioned by the staff persons that resident call buttons were working and that they could use those in case a resident needed to contact a care provider.

The regulations state that there shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. It was reported by staff persons that the facility did supply light to the residents’ bedrooms with lanterns.

Overall, it could not be proven that the facility's Emergency Disaster Plan was not sufficient regarding facility not supplying light to residents’ bedrooms.

Allegation: Facility did not have staff to serve meals to residents

The facility has written in their Sheltering In Place Procedures the following statement:
“In case of outage EVGV (Eskaton Village Grass Valley) has a generator that will power common areas, kitchen & hallways. EVGV has an emergency supply closet stocked with water, blankets, lanterns and batteries located in storage behind main elevator. The individual rooms will not have Heat/AC so we can open apartment doors to circulate air into each room. Residents will be asked to stay in their rooms and staff would perform regular well-being checks. Meals would be delivered to the room (in-room dining) as well as activities and engagement opportunities.”

During the interview process, staff persons reported that the facility was short staffed, as some staff persons could not get to work due to the snowstorm. It was reported that the kitchen had electricity and was preparing and providing meals to residents. Staff indicated that, although they were short staffed, the staff were able to get meals to the residents. Some staff reported that some residents were able to make it to the dining room and other residents ate their meals in their bedrooms.

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 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: 7 of 8

Control Number 25-AS-20211229094428

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

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

Based on interviews conducted by the Department and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 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: 8 of 8