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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005628
Report Date: 11/10/2020
Date Signed: 11/10/2020 10:12:22 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ESKATON LODGE GRANITE BAYFACILITY NUMBER:
317005628
ADMINISTRATOR:DELGADO, KIMBERLY (KIM)FACILITY TYPE:
740
ADDRESS:8550 BARTON RDTELEPHONE:
(916) 789-0326
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:118CENSUS: 92DATE:
11/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dina Jones (Life Enrichment)TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Konnor Leitzell contacted Dina Jones (Life Enrichment Director) regarding an incident report received by CCLD on 11/2. LPA was informed Kim Delgado is out on leave.

LPA requested Dina to resubmit the death report due to conflicting dates. LPA requested for staff who found resident to be identified in the Death Report as well. LPA requested Dina to include more detail regarding the the description of "conditions prior to or contributing to death".

LPA requested the following documents to be submitted to CCLD by COB 11/13/2020 for review:
  • Death Certificate from Chapel of the Valley
  • Residents 602
  • Residents Most Recent Care Plan
  • September and October Charting notes for Resident
  • Updated LIC624A (Death Report)


LPA thanked Dina for her time and conducted exit interview.

Report to be signed and returned by COB 11/10/2020. Keep one copy for facility records.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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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