315002052-2-2-2023-25-AS-TBAS-CNNPZZ-20230202104623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 02/02/2023
Date Signed: 02/02/2023 10:46:37 AM

Document Has Been Signed on 02/02/2023 10:46 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: 92	DATE:	02/02/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator, Adam Hill		TIME COMPLETED:	11:00 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	Licensing Program Analyst (LPA) Bains arrived at the facility unannounced on 02/02/2023 to conduct a case management visit 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. LPA Bains came to facility to conduct a case management visit due an incident that occurred at the facility for R1 for 06/06/2022. On 06/08/2022, the facility submitted an incident report to the Department indicating R1 sustained a fall incident at the facility on 06/06/2022 which resulted in R1s death at hospital on the same day. A review of additional incident reports submitted by the facility to the Department for R1 indicated R1 sustained falls on 05/0722, 05/26/22, 05/28/22 and 06/03/22. The Department investigated the incident and concluded that the fall R1 sustained on 06/06/2022 contributed to R1’s death. R1’s certificate of Death identifies “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. Medical reports indicated R1 underwent a Computerized Tomography (CT) Scan upon admittance to the hospital which showed R1 suffered a Holohemispheric Subdural Hemorrhage, a fatal injury, because of an unwitnessed fall that occurred at the facility on 6/6/2022. continued on LIC809C.......

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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: 02/02/2023

NARRATIVE

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*** Continued from LIC809........

Based on interviews with facility staff, staff were aware R1 was a fall risk as R1 fell twice (5/26/2022, 6/6/2022) in the hallway and three times (5/7/2022, 5/28/2022, 6/3/2022) During investigation, facility staff members (S1, S2, S3, S4) stated they were not instructed by management to provide any additional care to R1other than to “keep an eye on her” in case she was to fall. In addition, facility management staff stated that they did not issue special instructions to staff on additional care for R1 relating to her falling and that they did not believe R1 falling in the future could be avoided. Furthermore, management staff stated that their efforts were on R1s family obtaining Hospice Care for R1s to assist in R1s care. In addition to R1’s falls, care notes indicated the facility observed R1 with a decline in heath. R1s overall health was never re-evaluated by R1s physician; therefore, R1 never received an updated Needs and Services plan to prevent future falls.

Although the facility notified R1’s physician and responsible party of R1’s decline and falls, the facility did not reassess R1 due a change in condition after facility observed R1’s decline and R1 sustaining multiple falls. The facility did not put a plan in place for R1 to mitigate the risk of falls.

Based on investigation conducted, facility staff were aware R1 was a fall risk and did not put measures in place to provide adequate care and supervision to R1 resulted in R1 sustaining multiple falls that contributed to R1’s death.

The citation issued today is under review and a future civil penalty may apply based on Health and Safety code §1569.49(e) H&S. In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care. Failure to correct the deficiencies may also result in civil penalties.

Exit interview conducted. Appeal Rights provided. A copy of the report issued.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/02/2023 10:46 AM - 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ESKATON VILLAGE ROSEVILLE	FACILITY NUMBER: 315002052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/03/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466-Observation of the Resident- licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs……. This requirement is not as evidence by….	1 2 3 4 5 6 7	Licensee will make sure that Observation of for any resident per their health care needs/changes will be done in timely manner so residents care needs can be met per RCFE regulation 87466. Licensee shall submit letter of understanding of this regulation to CCL by POC date-02/03/23.
	8 9 10 11 12 13 14	Based on record review and interviews, it has been concluded that facility did not reassess R1 for unmet needs despite multiple falls incidents in May and June 2022 which poses immediate health and safety risks for residents in care.	8 9 10 11 12 13 14
Request Denied Type A 02/03/2023 Section Cited CCR87463(a)(3)	1 2 3 4 5 6 7	87463-Reappraisals-(a) The pre-admission appraisal shall be updated, in writing ....(3) (3) Any illness, injury, trauma, or change in the health care needs of the resident ....This requirement is not as evidence by…...	1 2 3 4 5 6 7	Licensee will make sure that re-appraisal will obtain for any resident per their health care needs/changes in timely manner so residents care needs can be met per RCFE regulation 87466. Licensee shall submit letter of understanding of this regulation to CCL by POC date-02/03/23.
	8 9 10 11 12 13 14	Based on record review and interviews, it has been concluded that facility did not document a reappraisal for R1 once it was identified R1 was declining and sustained multiple falls within a 2 months period (May and June 2022) which poses immediate health and safety risks for residents in care.	8 9 10 11 12 13 14

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/02/2023 10:46 AM - 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ESKATON VILLAGE ROSEVILLE	FACILITY NUMBER: 315002052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/03/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464-Basic Services-(f)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). This requirement is not as evidence by….	1 2 3 4 5 6 7	Licensee will make sure to provide care and supervision to residents so residents care needs can be met per RCFE regulation 87464. Licensee shall submit letter of understanding of this regulation to CCL by POC date-02/03/23.
	8 9 10 11 12 13 14	Based on record review and interviews, it has been concluded that facility did not provide proper care and supervision for R1 which resulted R1s fall and death on 06/06/22 which poses immediate health and safety risks for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

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