<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005628
Report Date: 04/30/2021
Date Signed: 04/30/2021 11:33:42 AM

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 LODGE GRANITE BAYFACILITY NUMBER:
317005628
ADMINISTRATOR:DELGADO, KIMBERLY (KIM)FACILITY TYPE:
740
ADDRESS:8550 BARTON RDTELEPHONE:
9167890326
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:118CENSUS: 82DATE:
04/30/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kimberly Delgado (ED)TIME COMPLETED:
11:45 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) Konnor Leitzell arrived at facility to conduct a Case Management Visit regarding a recent AWOL. CCL was notified of R1 leaving the premise without assistance on 4/26/2021, it was stated R1 left the facility twice in 24 hours, both times returning safely. In the incident reports submitted to CCL, it was stated R1 moved into facility very recently and left in search of a comb. Upon residents first returning, a wonder guard wrist monitor was placed on R1’s arm. The monitor did not notify facility of the second elopement. Resident was located by Sheriff's department shortly after and safely returned to facility.

During today’s visit LPA conducted interviews and reviewed documents. Through the interviews and documents reviewed, LPA was informed of the following. R1’s 602 stated they did not show signs of wondering; and since the incident Friday R1 has been discharged and moved to Eskaton Lodge Roseville. Eskaton Roseville has a different floor plan, with less accessible exits, and is more conducive for wonder risk residents.

When asking why the wonder guard did not work when R1 eloped the second time, ED informed LPA that it was an issue with the system, and they have since fixed the issue. LPA was informed Stanley System (wonder guards) rolled out an update recently, but failed to inform the facility they were required to reset all monitors for the update to be effective. This allowed for a momentary delay of when the exit sensor read the wonder guard. Facility staff have since reset all exit sensors, and tested all wonder guards to ensure they work successfully. Interview with staff reviled that prior to providing R1 with the wonder guard, staff checked to make sure batter was 100%, changed the name to the Resident, and tested the monitor on a side glass door. The monitor worked, but staff believes there was a delay that allowed R1 to leave undetected.

Cont LIC 809C
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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
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 LODGE GRANITE BAY
FACILITY NUMBER: 317005628
VISIT DATE: 04/30/2021
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
26
27
28
29
30
31
32
LPA was informed upon R1’s return from the first elopement, staff provided R1 with a comb from their in house beauty practitioner. Staff are unsure of the reasoning for the second elopement. LPA was informed facility currently has twelve (12) residents that are not allowed to leave unassisted due to diagnosis of dementia, with three (3) using the wonder guards. No current AWOL issues with other residents.

LPA conducted exit interview with Kim Delgado (ED), thanking her for her time and speaking with me. LPA provided ED with a signed copy of the report, and informed ED she is to keep one copy of the report for facility files. No deficiencies cited during visit.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2