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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 04/02/2024
Date Signed: 04/02/2024 11:07:32 AM


Document Has Been Signed on 04/02/2024 11:07 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 ROSEVILLEFACILITY NUMBER:
315002052
ADMINISTRATOR:HILL, ADAMFACILITY TYPE:
740
ADDRESS:1650 ESKATON LOOPTELEPHONE:
(916) 789-7831
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:125CENSUS: 95DATE:
04/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Adam Hill, Administrator TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA arrived to the facility and met with Administrator Adam Hill and Tricia Diaz.

Facility sent an incident report into CCL concerning an incident that occurred on 3/28/24. LPA interviewed administrator concerning incident and obtained resident documents.

No deficiencies cited during today's inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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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