347001241-1-4-2023-27-AS-KHOS-CMZRCJ-20230112115426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 01/04/2023
Date Signed: 01/04/2023 10:39:24 AM

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
11/07/2022 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20221107143758

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: 77	DATE:	01/04/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Neglect/Lack of Supervision:
1) Resident sustained a broken arm while in care due to lack of staff supervision.
2) Staff are not attending to resident's hygiene needs while in care.
3) Staff do not ensure that resident is wearing clean clothing while in care.
Reporting requirements:
1) Staff did not report an incident involving a resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Eskaton Gold River Lodge (RCFE) on 1/4/23 at 9:15am 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 was unable to corroborate any of the above allegations. LPA attempted to interview the alleged victim on several occasions and each time the resident refused to be interviewed by LPA. Additionally, LPA observed resident to be clean and in clean clothing each time resident was observed by LPA. Staff interviewed each identified specific bathing dates and could not be corroborated by resident as she refused interviews. LPA reviewed resident's clothing inventory and LPA observed a limited suppy of tops which may account for resident being observed in the same clothing. Additionally, LPA and the department received an incident report from the facility regarding the fall and subsequent injury to the resident. Based on interviews and information obtained LPA could not identify and neglect or lack of supervision that resulted in the resident falling and sustaining an injury.

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: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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-20221107143758

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: 01/04/2023

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 Personal Rights and 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, DIVISION 6, CHAPTERS 1 & 5.

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: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

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