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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340313383
Report Date: 03/23/2022
Date Signed: 03/23/2022 05:04:26 PM

Document Has Been Signed on 03/23/2022 05:04 PM - 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 VILLAGEFACILITY NUMBER:
340313383
ADMINISTRATOR:KLICK, GREGFACILITY TYPE:
741
ADDRESS:3939 WALNUT AVETELEPHONE:
(916) 974-2000
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 500CENSUS: 53DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Erik Olson, Assistant Executive Director and Evelyn Stinebaugh, Resident Care CoordinatorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Erik Olson, Assistant Executive Director and Evelyn Stinebaugh, Resident Care Coordinator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): KN95 mask.

LPA, Assistant. Executive Director and Resident Care Coordinator toured the interior of ALU, including the medication room, staff break room, bathroom, common areas and resident hallways. LPA observed all areas toured to be clean, in good repair and odor free and the bathrooms to have hand-washing posters, paper towels, soap and trash cans with lids. LPA observed various Covid-19 posters posted throughout both areas of the facility and at the entrances to each unit.

LPA, Assistant Executive Director and Resident Care Coordinator completed the infection control domain, and the facility was found to be in compliance at this time. Inside temperature was observed to be 73* F. Vaccination status of residents and staff were discussed, as well as visitation protocols per PIN 22-07 issued 2/7/2022. Facility is maintaining documentation of visitor vaccination or negative test result. Staff testing requirements were also discussed. LPA observed signage posted at the front entrances that masks are required upon entry.

LPA requested a copy of LIC500 and current liability insurance be emailed to CCLD by 3/31/12022.

There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to
Resident Care Coordinator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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