297001933-12-12-2022-25-AS-MSEY-CM5NET-20221215092428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 297001933
Report Date: 12/12/2022
Date Signed: 12/12/2022 12:12:29 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
12/05/2022 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221205155358

FACILITY NAME:	ESKATON VILLAGE GRASS VALLEY		FACILITY NUMBER:	297001933
ADMINISTRATOR:	HAMMAM, TIGHE		FACILITY TYPE:	740
ADDRESS:	625 ESKATON CIR		TELEPHONE:	(530) 273-1778
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	160	CENSUS: 118	DATE:	12/12/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cameron Uhlir		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff did not adhere to COVID-19 protocol
Faciltiy does not have adaquete staff to meet the needs residents' needs

INVESTIGATION FINDINGS:

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LPA Parks arrived on Monday December 12, 2022 to conduct a complaint investigation regarding the above allegations. Prior to the visit, LPA completed the required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA discussed the allegations with the Administrator. Additonally, LPA interveiwed staff and obtained staffing schedules. LPA learned the following: while there was an event in November to celebrate the facility's 20th anniversary, all proper covid precuations were followed. Interviews revealed that children and guests were wearing masks at all times. Additonally, while the children performed 4 songs for the residents, masks were. The facilty had children's masks on hand, but were not needed as the children arrived with masks. While the facility has had a current covid outbreak, this was traced back to a resident's event outside of the facility.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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 25-AS-20221205155358

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ESKATON VILLAGE GRASS VALLEY	FACILITY NUMBER: 297001933
	VISIT DATE: 12/12/2022

NARRATIVE

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LPA obtained a copy of the December staffing schedule as well as the daily staff schedule for AL and MC. LPA interviewed staff regarding current staffing. Staff interviews revealed that if there is an open shift, facility will utilize staffing agency to assist. The facility currently can obtain agency staff from 4 agencies. No interviews revealed insufficient staffing which resulted in a resident not being assisted from a fall.

Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was left at the facility

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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