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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340313383
Report Date: 09/13/2023
Date Signed: 09/13/2023 04:10:35 PM

Document Has Been Signed on 09/13/2023 04:10 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 412DATE:
09/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Greg KlickTIME COMPLETED:
04:30 PM
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On 9/13/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Executive Director, Greg Klick .

On 3/20/23, the department received a complaint alleging R1's dietary restrictions were not followed for R1 and that R1 was not provided identified assistance while eating.

In addition to the investigated allegations Inspections, records and interviews found that in addition to the failure on the parts of S3 and S4 to properly prepare the food for R1 on 3/11/23, the investigation also found: S3’s and S4’s incidents of, as their terminations letters state- “multiple residents have received food that was not appropriately prepared”- had not been addressed in supervisor action prior to the incident on 3/11/23; that the procedures in place did not address individual meal verification when delivered to resident rooms; and that S1 was not provided appropriate training regarding R1’s dietary needs and assistance with cutting food. This constituted a failure on the part of the administrator to provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and need.

Furthermore, the incident report and death report provided by the licensee to investigators failed to be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified and did not include the nature of event and disposition of the case.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ESKATON VILLAGE
FACILITY NUMBER: 340313383
VISIT DATE: 09/13/2023
NARRATIVE
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As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
      Report reviewed with Executive Director. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2023 04:10 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 09/13/2023 at 02:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESKATON VILLAGE
FACILITY NUMBER: 340313383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2023
Section Cited
CCR
87405(h)(5)

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Administrator - Qualifications and Duties (h)(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs… this requirement was not met based on records and interviews that found insufficent training and oversight over
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The management eam has discussed and implemented measures.Licensee will submit a statement of specific oversight measures on the part of the administrator to ensure resident care needs are met by the POC date of 9/18/23.
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special diet services to residents and supervision of food service staff which contributed to a resident death.
This posed an immediate risk to resident's health and safety.
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Type B
09/28/2023
Section Cited
CCR87211(a)(1)

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Reporting requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified .... This report shall include the …nature of event… and disposition of the case.
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Licensee will submit proof of training for all employyes reposible for reporting to CCL reguarding timeliness of reports and detailed information in the report as outlined in LIC 624 and LIC 624a.
POC due by 9/28/23.
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This requirement was not met based on records of incident and death report regarding R1 on 3/11/23 that failed to report timely and did not contain the nature of the event.
This posed a potential risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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