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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001241
Report Date: 09/02/2022
Date Signed: 09/02/2022 11:32:05 AM


Document Has Been Signed on 09/02/2022 11:32 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: DATE:
09/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Neal TorresTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management visit at Eskaton Gold River Lodge on 9/2/22 at 9:20am to address concerns regarding resident who expired on 5/30/22. LPA Gould met with Neal Torres and together discussed the departments findings regarding the resident’s death.

The department conducted interviews with 5 staff members, 4 residents and family of deceased resident. The Department also conducted review or resident file including incident reports dated 5/30/22, resident progress notes dated 5/14/22. Physician’s report (LIC 602) dated 1/28/22, Resident functional evaluation dated 3/11/22, Admission Agreement dated 1/28/22. Pre-Placement appraisal dated 1/24/22.

Based on the interviews and documents obtained during the investigation process, the department has determined the facility, upon being informed of R1’s intentions of self-harm by R1’s family member on 5/14/22, did not have R1 re-evaluated once staff were informed of a change in mental condition. Additionally, staff who was informed of R1’s suicidal ideation did not notify additional staff members. The department has determined the facility did not adequately address the concerns by reassessing R1 and implementing a suicide intervention plan to include frequency of health checks for R1. The department has also determined, upon discovery of R1 in distress, staff who discovered R1 did not immediately contact 911 and sought additional staff support which may have delayed emergency medical personnel in providing emergency medical care to R1.

Per California Code of Regulations, Title 22, the following deficiencies and immediate civil penalty have been issued. The circumstances of this Case Management are being evaluated for enhanced civil penalties. An exit interview was conducted and a copy of this report and appeal rights were 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: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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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Document Has Been Signed on 09/02/2022 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/06/2022
Section Cited

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Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: A
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mental/social trauma such as the loss of a loved one. This requirement was not met as evidenced by facility staff did not arrange for R1 to be reappraised after being informed of R1’s statements of suicidal ideation on 5/14/22 which poses an immediate health, safety and personal rights risk to residents in care.
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Deficiency Dismissed
Type A
09/06/2022
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by facility did not provide
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enhanced safety checks for resident who expressed suicidal ideation on 5/14/22 resulting in resident committing suicide on 5/30/22 which poses an immediate 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: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/02/2022 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/06/2022
Section Cited

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Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This
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requirement was not met as evidenced by when staff discovered R1 the staff did not immediately contact 911 for emergency services and instead sought additional support from additional facility staff which may have delayed first responders from initiating timely aid to the resident which poses an immediate health, safety and personal right 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: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
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