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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:15:47 PM

Document Has Been Signed on 11/02/2023 02:15 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: 102DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Adam Hill, Administrator TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management inspection. LPA met with Administrator Adam Hill and Tricia Diaz, Resident Care Coordinator.

LPA received a report from the facility concerning an incident that occurred on 9/11/23. R1 was a memory care resident and was found outside of the facility on the facility patio by staff. Facility investigated the incident and found that a caregiver had let R1 out of the memory care unit due to a misunderstanding. R1 was immediately brought back to the memory care unit and responsible party was notified. Administrator stated training was provided to care staff the following day.

Due to the information gathered, deficiencies are cited on 809-D. Appeal rights provided.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/02/2023 02:15 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 11/02/2023 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ESKATON VILLAGE ROSEVILLE
FACILITY NUMBER: 315002052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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 This requirement was not met based on records of the incident of R1 AWOL from the facility memory care unit on 09/11/23. This posed a potential risk to the resident.
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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 Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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