315002052-8-25-2022-25-AS-TBAS-CHMNY8-20220825105220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 08/25/2022
Date Signed: 08/25/2022 10:52:30 AM

Document Has Been Signed on 08/25/2022 10:52 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	ESKATON VILLAGE ROSEVILLE		FACILITY NUMBER:	315002052
ADMINISTRATOR:	HILL, ADAM		FACILITY TYPE:	740
ADDRESS:	1650 ESKATON LOOP		TELEPHONE:	(916) 789-7831
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	125	CENSUS: 86	DATE:	08/25/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Adam Hill		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/25/22 to conduct a case management inspection to follow up on a recent AWOL for R1 and few fall incidents for R2 and R3 at the facility. LPA met with facility Administrator Adam Hill and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. LPA was screened by facility staff upon entry. R1’s AWOL Incident- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 08/11/22 regarding resident (R1) leaving the facility unattended on 08/10/22, at approximately 7.00pm. Per incident report, R1 was last seen around 6.25pm close to exit door and found outside the facility unassisted by a homeowner who notified the campus patrol person. R1 was brought back to facility uninjured around 7pm with facility staff. LPA followed up with memory care coordinator after this incident and gathered information for R1 including LIC602, Admission Agreement and care notes. Facility notified R1s doctor and family on 08/10/22 regarding this AWOL incident. R1's physician's report from 05/14/22 indicates that resident has diagnosis of dementia and cannot leave the facility unassisted. This was first AWOL incident for R1 since her admission to the facility. Resident has not tried to leave facility again and has been communicating better with the staff if R1 needs something. to be continued on 809-C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ESKATON VILLAGE ROSEVILLE	FACILITY NUMBER: 315002052
	VISIT DATE: 08/25/2022

NARRATIVE

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R2’s Fall Incidents- The department has received incidents reports (LIC624) for R2 for date 08/13/22 and for 08/21/22 regarding R2s fall incidents. R2s doctor and family been notified regarding these fall incidents. R2 did not sustain any remarkable injuries from these fall incidents. Facility care staff has increased monitoring for R2 after these fall incidents and will report for any health changes to R2s doctor, family and to department.

R3’s Fall Incidents- The department has received incidents reports (LIC624) for R3 for date 08/09/22, 08/10/22, 08/13/22 and for 08/21/22 regarding R3s fall incidents. R3s doctor and family been notified regarding these fall incidents.Facility care staff has increased monitoring for R3 after these fall incidents and will report for any health changes to R3s doctor, family and to department.

The facility has been continuously addressing the falls and implementing measures to prevent the falls/AWOL incidents from occurring in the future to ensure the health and safety of residents in care.

LPA did facility tour during today's visit, interviewed memory care director and 2 facility staff regarding these incidents. Several topics have been discussed during today's visit.

No citations were issued at this time and only Technical Advisory has been issued to the facility.

Exit interview conducted. Copy of report provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC809 (FAS) - (06/04)

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