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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297001933
Report Date: 04/06/2023
Date Signed: 04/06/2023 11:23:59 AM


Document Has Been Signed on 04/06/2023 11:23 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:ESKATON VILLAGE GRASS VALLEYFACILITY NUMBER:
297001933
ADMINISTRATOR:CAMERON UHLIRFACILITY TYPE:
740
ADDRESS:625 ESKATON CIRTELEPHONE:
(530) 273-1778
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:160CENSUS: 130DATE:
04/06/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Alicia RistTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday April 6, 2023 to conclude the annual inspection. LPA wore a surgical mask during todays inspection.

During today's visit, the Compliance and Regulatory Enforcement Tool was used. LPA completed the CARE Tool for the annual inspection.

LPA obtained a copy of the staff evacuation chair training.

LPA is requesting a copy of the facility's current LIC500, LIC610E, and current liability insurance by the end of the month.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator. .
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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