347001241-12-20-2022-27-AS-CACL-CMCQGU-20221222111008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:57:22 PM

Unsubstantiated

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
09/14/2022 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20220914143505

FACILITY NAME:	ESKATON GOLD RIVER LODGE		FACILITY NUMBER:	347001241
ADMINISTRATOR:	NEAL TORRES		FACILITY TYPE:	740
ADDRESS:	11390 COLOMA RD		TELEPHONE:	(916) 852-7900
CITY:	GOLD RIVER	STATE: CA	ZIP CODE:	95670
CAPACITY:	134	CENSUS: 73	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Neal Torres		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Personal Rights:
1) Facility staff changed resident's needs and service plan without conducting a reappraisal involving resident's doctor and authorized person.
2) Facility staff retaliated against resident for complaining

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Eskaton Gold River Lodge (RCFE) on 12/20/22 at 1:30pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because LPA could not corroborate the allegations. LPA reviewed resident's file and conducted interview. LPA also conducted interviews with appropriate staff members including administrator and head of nursing. LPA determined that resident did in fact make statement of self harm whereby the facility staff, upon being notified of self harm statements by resident initiated the facility plan for 1 on 1 supervision for resident until the resident could be re-evaluated by a physician and cleared to return to regular supervision. LPA and the department have determined that the enhanced supervision was not a change of the resident's needs and services plan but as part of ensuring the resident's immediate health and safety. Once resident had been re-evaluated by a physician the 1 on 1 staff supervision was discontinued with immediate effect.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220914143505

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: 12/20/2022

NARRATIVE

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LPA also could not determine if the facility was retaliating against a resident for a prior complaint as the facility followed all protocol of the plan approved by the department when a resident makes statements of self harm. No facility staff interviewed identified the steps taken as part of retaliation by the facility.

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 Personal Rights 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 the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

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