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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 01/03/2024
Date Signed: 01/03/2024 02:28:36 PM


Document Has Been Signed on 01/03/2024 02:28 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:ESKATON VILLAGE ROSEVILLEFACILITY NUMBER:
315002052
ADMINISTRATOR:HILL, ADAMFACILITY TYPE:
740
ADDRESS:1650 ESKATON LOOPTELEPHONE:
(916) 789-7831
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:125CENSUS: 98DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adam Hill, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual inspection. LPA met with Administrator Adam Hill upon arrival. Currently there are 98 residents of which 14 residents are receiving hospice care.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 10 resident files and 10 staff files. LPA reviewed 4 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA observed a copy of current liability insurance. LPA observed not all care staff had updated CPR and first aid certificates.

Deficiencies are cited on 809-D.

Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
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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Document Has Been Signed on 01/03/2024 02:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 ROSEVILLE

FACILITY NUMBER: 315002052

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 9 out of 38 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Administrator agrees all 9 staff members will receive CPR and first aid certificates. Updated certificates to be sent into LPA by 1/19/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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