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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 02/26/2025
Date Signed: 02/26/2025 01:28:08 PM

Document Has Been Signed on 02/26/2025 01:28 PM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ESKATON VILLAGE ROSEVILLEFACILITY NUMBER:
315002052
ADMINISTRATOR/
DIRECTOR:		RIST, ALICIAFACILITY TYPE:
740
ADDRESS:1650 ESKATON LOOPTELEPHONE:
(916) 789-7831
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 125CENSUS: 87DATE:
02/26/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Kay DeVault, Business ManagerTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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Licensed Program Analysts (LPAs) Cassandra Mikkelson and Cheyenne Ratajczak arrived at the facility and met with Business Services Manager Kay DeVault for a case management visit.

LPAs followed up regarding a LIC624 sent to CCLD regarding resident R2's blood sugar levels. LPAs reviewed medication records, blood sugar logs and R2's physician's report. LPAs reviewed records which indicated facility followed proper protocols regarding incident.

LPAs followed up regarding incident involving Resident #1 (R1) was being financially abused by the nail salon services for about a year. LPAs reviewed termination letter given to vendor dated February 11, 2025. LPAs also reviewed new policies and new consent form with Kay DeVault and Executive Director Alicia Rist, on the phone, that has been put into place.

At this time, deficiencies are not being cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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