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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005628
Report Date: 12/17/2021
Date Signed: 12/17/2021 11:33:41 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:
(916) 789-0326
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:118CENSUS: 91DATE:
12/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kim DelgadoTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) L. Muscan and K. Hiratsuka arrived at the facility unannounced on 12/17/2021 to conduct a Case Management visit. LPAs met with Facility Administrator Kim Delgado and explained the purpose of the visit. Prior to initiating the visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and contacted Facility Representative and completed a facility risk assessment. LPAs ensured they applied hand sanitizer prior to entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPAs were screened by Receptionist.

The reason for the visit today was due to an Incident report the facility submitted. The incident in question took place 12/14/2021. The resident in question had something stuck in their throat and sent to hospital. During today's visit facility provided documentation the resident required no assistance with their activities of daily living prior to the incident Facility is reassessing resident upon return from hospital.

Due to information provided, no deficiencies were cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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