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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001241
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:04:16 PM


Document Has Been Signed on 05/04/2023 01:04 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
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: 78DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Neal TorresTIME COMPLETED:
01:15 PM
NARRATIVE
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On 5/4/23 at 9:10am, Licensing Program Analyst (LPA) Kevin Gould conduced and unannounced Case management inspection to address concerns with reported medication administration errors reported on 4/16/2023 and 4/23/2023. LPA met with Neal Torres and together discussed the reported incidents.

It was disclosed to LPA that one resident has a complex insulin administration schedule and the two errors were made by two different staff members. in one instance the incorrect insulin was administered, the error was noticed immediately and physician and poison control were contacted at instructions followed. On the second instance the insulin was administered 4 hours earlier in conjunction with another insulin dose. Physician and poison control were contacted at instructions followed.

One of the staff members has already participated in medication administration retraining. the second staff member will receive medication administration training in the near future. The facility has informed LPA that they have installed a new regimen for insulin administration and they are in the process of approving and adopting an electronic medication administration record (MAR).

Per California Code of Regulations, Title 22, the following deficiency is cited and due to a previous citation in the past 12 months, a civil penalty is issued.

An exit interview was conducted an 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: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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Document Has Been Signed on 05/04/2023 01:04 PM - 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: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited

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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 incorrect doses of insulin on 4/16
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Facility will conduct medication administration retaining for both staff members responsible for medication errors and will provide the department with a written explanation of the new medication administration process for insulin for all residents.
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and 4/26 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: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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