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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005628
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:13:18 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2022 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20220822130038
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: 85DATE:
10/31/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Kim DelgadoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Facility does not meet resident’s incontinence needs.
Facility does not meet resident’s dietary needs.
Staff do not assist resident with grooming.
INVESTIGATION FINDINGS:
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On 10/31/22, Licensing Program Analysts (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator, Kim Delgado. Prior to visit, LPA 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. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 25-AS-20220822130038
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ESKATON LODGE GRANITE BAY
FACILITY NUMBER: 317005628
VISIT DATE: 10/31/2022
NARRATIVE
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Facility does not meet residents’ incontinence needs.
Facility does not meet residents’ dietary needs.
Staff do not assist resident with grooming.

LPA Muscan interviewed 4 staff and 6 residents on 9/21/2022. LPA toured facility and viewed the meal and dining area at lunch time. LPA observed a special diet board in the kitchen area for residents with special dietary needs. LPA has reviewed facility records, including charting notes, menus, staff schedule, and resident records. Interviews indicated that resident’s ADL’s. Interviews indicated state the residents showering, incontinence, and dietary needs, and needs of others are met as required and documented accordingly. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2022 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20220822130038

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: DATE:
10/31/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Kim DelgadoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not regularly observe resident for change in condition.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
During the complaint investigation, records were reviewed, and interviews were conducted. LPA observed staff documentation and notifications to residents’ physicians when change in condition occurred. In addition, the Administrator and staff have been in communication and meeting with the family regarding concerns of R1s condition. LPA observed a handwritten log where staff note resident's appetite, sleep habits, bowel & bladder output and any unusual health or behavioral issues daily. Staff documents checks, in log, which is located on dining room table for family and other caregiver reference. The resident’s file show regular annual physician visits and other routine visits for routine checkups. The facility documents incidents in daily notes for all residents. This agency has investigated the complaint alleging (Staff do not regularly observe resident for change in condition). We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3