347001241-4-18-2024-27-AS-KHOS-D4LNT9-20240423104422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 04/18/2024
Date Signed: 04/18/2024 12:01:16 PM

Unsubstantiated

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
02/16/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240216084025

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: 87	DATE:	04/18/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Neal Torres		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Licensee does not ensure injections are administered by resident or an appropriately skilled professional

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Neal Torres and explained the purpose of the visit.

This investigation consisted of interviews and record review. During the course of this investigation, LPA Moleski interviewed Torres, three residents (R1-R3), seven medication technicians (S2-S8), and one licensed nurse (S1). According to Torres, four residents were taking injectable insulin (R1-R4) at the onset of this investigation. R4 has been out of this facility and is currently at a skilled nursing facility.

LPA Moleski reviewed four months' worth of medication administration records for R1-R4’s injectable medications. LPA Moleski compared employee initials in these records to a list of employees and observed that initials for these injectable medications corresponded with the initials of licensed nurses, or with medication technicians. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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-20240216084025

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: 04/18/2024

NARRATIVE

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In interviews, Torres and S1 said that medication technicians had been trained to provide hand-over-hand assistance for residents who self-inject medications starting in mid-January. LPA Moleski reviewed training records for all medication technicians. All completed their training around the end of January.

During interviews, S2-S8 said that they had provided varying degrees of assistance to residents who self-inject medications. All staff members interviewed were able to adequately describe proper medication assistance techniques. S2-S8 all denied having performed an injection for any resident. None of these staff members had personally witnessed another medication technician or other unlicensed person administering medication injections to residents. Staff members S2, S3, S4, S5, and S7 had heard rumors of an unlicensed staff member or staff members having done so, but did not provide any specific details. In an interview, S1 said S1 was not aware of any unlicensed persons administering medication injections to residents.

In an interview, R1 was not aware of receiving injections, and was not able to articulate how R1 receives their injectable medications. In an interview, R2 said R2 is able to insert the syringe, and receives assistance pushing down the plunger. In an interview, R3 said R3 is able to insert the syringe. R3 was not able to provide further detail, but was confident that R3 was able to “do it.”

The department has determined the following as it relates to the allegation that the licensee does not ensure injections are administered by a resident or an appropriately skilled professional:

Based on interviews and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Torres.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

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