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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002052
Report Date: 06/07/2021
Date Signed: 06/07/2021 11:17:17 AM



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
07/28/2020 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 27-AS-20200728085720
FACILITY NAME:ESKATON VILLAGE ROSEVILLEFACILITY NUMBER:
315002052
ADMINISTRATOR:CROSS, VICKYFACILITY TYPE:
740
ADDRESS:1650 ESKATON LOOPTELEPHONE:
(916) 789-7831
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:125CENSUS: 77DATE:
06/07/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:ADAM HILL, ADMINISTRATORTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
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5
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9
Residents needs are not being met due to lack of staff.
INVESTIGATION FINDINGS:
1
2
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5
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7
8
9
10
11
12
13
Donna Gurriere, Licensing Program Analyst (LPA) was in contact with Adam Hill, Administrator. It was alleged that during the month of July 2020, Residents needs were not being met due to lack of staff.
An investigation was conducted, and the previous administrator, previous resident care coordinator, the current administrator and three staff persons were interviewed. In addition, documents that were reviewed, included two resident assessments, two resident logs with a checklist of two-hour checks by facility staff persons. The two residents were not interviewed, as one is on hospice and not well, and the other resident no longer resides at the facility.
During the interview process, the administrator reported that he was not working during the time of the allegation; therefore, he was not able to comment. All the staff persons indicated that the allegation is untrue and that it was reported that at times, staff may have had a shortage of staffing; however, the staff were always available to meet the resident’s needs.
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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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