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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:24:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20220802145540
FACILITY NAME:ESKATON GOLD RIVER LODGEFACILITY NUMBER:
347001241
ADMINISTRATOR:NEAL TORRESFACILITY TYPE:
740
ADDRESS:11390 COLOMA RDTELEPHONE:
(916) 852-7900
CITY:GOLD RIVERSTATE: CAZIP CODE:
95670
CAPACITY:134CENSUS: 79DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Karen Peets, LVNTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Medication: Facility staff did not dispense correct amount of medication to resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Eskaton Gold River Lodge (RCFE) on 10/21/22 at 1:50pm to conclude the investigation of the above allegation and to deliver the findings. LPA met with Staff Karen Peets and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated because Resident #1 was confirmed to have received an additional dose of once-weekly medications administered the day following their scheduled dose. Staff interviewed and incident reports received from the facility confirmed the allegation.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medication is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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 5
Control Number 27-AS-20220802145540
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ESKATON GOLD RIVER LODGE
FACILITY NUMBER: 347001241
VISIT DATE: 10/21/2022
NARRATIVE
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The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220802145540
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ESKATON GOLD RIVER LODGE
FACILITY NUMBER: 347001241
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and additional dose of weekly medication
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Facility will conduct retraining for staff identified as responsible for the medication error and provide documentation of medication administration training to the department by the POC due date.
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which poses an immeated health, safety and personal rights risk to residents in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20220802145540

FACILITY NAME:ESKATON GOLD RIVER LODGEFACILITY NUMBER:
347001241
ADMINISTRATOR:NEAL TORRESFACILITY TYPE:
740
ADDRESS:11390 COLOMA RDTELEPHONE:
(916) 852-7900
CITY:GOLD RIVERSTATE: CAZIP CODE:
95670
CAPACITY:134CENSUS: 79DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Karen Peets, LVNTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Eskaton Gold River Lodge (RCFE) on 10/21/22 at 1:50pm to conclude the investigation of the above allegation and to deliver the findings. LPA met with Staff Karen Peets and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because Resident #1 sustained his first fall on the date of the allegation in the morning prior to receiving his additional dose of medication in error. LPA confirmed that the facility followed protocols and contacted poison control and the resident's primary care physician after the error occured and the facility did not receive any direction from either poison control or the resident's physician that vertigo would be a side effect of additional medication administration. Facility insituted additional checks, prevented resident from laying down per the physician's instructions and ensured resident stayed hydrated throughout the day. Facilty also attempted to have resident sent to the hospital for evaluation wich was declined. LPA was unable to obtain any corroborating evidence that medication error was a direct result of resident's fall and or injury.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220802145540
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ESKATON GOLD RIVER LODGE
FACILITY NUMBER: 347001241
VISIT DATE: 10/21/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5