347001241-2-7-2024-27-AS-KGOD-D28Q57-20240207105128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 02/07/2024
Date Signed: 02/07/2024 10:51:28 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2023 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230705114802

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: 78	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Neal Torres		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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This report is being amended to revise the findings delivered on 11/16/23 as the department has obtained additional information regarding the allegations.

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Eskaton Gold River Lodge (RCFE) on 2/7/24 at 9:15 am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Neal Torres and together discussed the investigation details.
Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. Based on the department’s investigation, on 6/25/23 the deceased resident exited the facility front doors after an unknown guest had unlocked the front doors to exit the facility. When staff arrived to ensure guests exited appropriately, staff observed guests had already left, the staff member looked around the front porch of the facility and then locked the doors with resident outside the facility.

Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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-20230705114802

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESKATON GOLD RIVER LODGE	FACILITY NUMBER: 347001241
	VISIT DATE: 02/07/2024

NARRATIVE

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Although the facility had an agreement in place with the family and resident for no room overnight checks for the resident to not disturb the resident’s dog, the department has identified the facility did not meet their own requirements of two hour room checks that should have been conducted per facility’s plan of operation. Resident left the facility at approximately 7:30pm and there were no checks on the resident after that time. Per the family and facility there was an agreement for no checks from 10:00pm to 6:00am. As a result, no staff checked on the resident to ensure their health safety or whereabouts for the resident from the time period of 7:30pm to 10:00pm which exceeds the time limit identified in the facilities plan of operation. The department has also obtained a copy of the coroner’s report regarding the death of former resident. The coroner’s determination of death for the resident is hypothermia.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Questionable Death is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22 and an immediate civil penalty has been issued. The circumstances of this complaint are being evaluated for additional civil penalties.

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) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230705114802

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESKATON GOLD RIVER LODGE	FACILITY NUMBER: 347001241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/08/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by resident (R1) was witnessed on video leaving the facility at 7:30pm, the facility doors were locked while the resident	1 2 3 4 5 6 7	facility will establish a documentation of resident whereabouts and confirm their presence at the facility at the beginning and end of each shift. facility will submit a written plan establishing the supervision of residents.
	8 9 10 11 12 13 14	was still outside walking their dog. As a result, the resident was not noticed as missing and was not discovered by staff until the following morning. The coroner’s determination of death for the resident is hypothermia. Per the facility plan of operation, supervision would include health checks for all residents at a minimum of every two hours. R1 and the facility had a no check agreement from 10pm until 6am. Per the facility’s plan of operation, R1 should have been checked on between the time they exited the facility until R1’s agreed upon no check time that exceed two hours and was not consistent with the facility’s own plan of operation which poses an immediate health safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
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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-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

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