315002052-3-6-2024-59-AS-BMII-D34NVM-20240306094810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 03/06/2024
Date Signed: 03/06/2024 09:49:03 AM

Document Has Been Signed on 03/06/2024 09:49 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

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: 96	DATE:	03/06/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Tricia Diaz, Resident Care Coordinator		TIME COMPLETED:	10:00 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	On March 6, 2024, Licensing Program Analysts (LPA) Bethany Mirlohi and Talwinder Bains conducted a case management visit to follow up on a case management visit conducted at the facility on February 2, 2023. LPA Bethany Mirlohi and Talwinder Bains met with Tricia Diaz and explained the purpose of the visit. On February 2, 2023, the Department concluded an investigation from a self-reported incident that occurred where R1 sustained a fall at the facility on June 6, 2022, which resulted in R1s death at the hospital on the same day. R1’s death certificate indicates R1’s “Cause of Death” as Acute Subdural Hematoma with Shift, Mechanical Fall, Acute Respiratory Failure, and Acute Cardiac Arrest; and states R1 suffered an unwitnessed, ground level fall. The licensee was cited for California Code of Regulations (CCR), Title 22 Division 6, Chapter 8, § 87464(f)(1) states in part, “Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). At the time of the Case Management visit on February 2, 2023, an immediate civil penalty in the amount of $500 was issued, and the license was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49. Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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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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
	VISIT DATE: 03/06/2024

NARRATIVE

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The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced as facility management’s failure to reappraise R1 after R1 suffered five unwitnessed falls in a two-month period, the final fall resulting in R1’s death. The facility should have implemented enhanced care and supervision to mitigate the resident's risk of falls.

Today, March 6, 2024, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(d) in the amount of $15,000 for a violation that the Department determines resulted in the death of a resident. However, since an immediate civil penalty of $500 was previously issued on February 2, 2023, the amount of the civil penalty issued today will be $14,500.

A copy of the LIC 421D was given to the facility representative.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Tricia Diaz signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

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