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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:18:23 PM

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
02/29/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240229151350
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: DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Neal Torres TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not follow protocols to prevent the spread of illness.
Staff did not assist resident in a timely manner.
INVESTIGATION FINDINGS:
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On 09/17/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. The LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). The LPA met with Executive Director, Neal Torres and a brief interview followed.

Regarding: Staff did not follow protocols to prevent the spread of illness.

On 02/23/24, 4 residents were temporarily relocated to Eskaton Gold River Lodge from Eskaton Village in Carmicheal due to a flood in the memory care community in Carmicheal. This LPA learned through interviews that one of the resident's at the Carmicheal facility tested positive for COVID prior to being transferred to a third Eskaton facility in another city. This LPA also learned through interviews that all of the other residents being relocated tested negative for COVID prior to transfer.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20240229151350
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: 09/17/2024
NARRATIVE
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LPA received a document from a staff member (S4) dated 2/22/24. It confirmed that a resident at Eskaton Village tested positive for Covid. It also confirmed that this information was communicated from Eskaton Village to Eskaton Gold River prior to the transfer of residents.

The Memory Care Coordinator at Eskaton Gold River stated that she was not informed that a resident had tested positive for Covid at the Eskaton Village facility and therefore had not taken any special precautions.  Additional care staff were not brought in, however another Enrichment Assistant was added to help the newcomers engage with the community and to decrease any anxiety they might have felt over their sudden change in environment.

During a review of the Coronavirus/COVID-19 Preparedness and Response Plan, (the Plan) dated 09/14/2022 by Eskaton Gold River Lodge, page 17 stated that, "New move-ins should be tested at the time of move-in.  This can be done with a PCR or rapid antigen test." This was not done.  3 out of 3 staff interviewed stated that there was no mention of these residents potentially being exposed to COVID-19 and they were not screened, isolated, or masked. 

In an interview with S4, this LPA learned that the newcomers were seated together for meals in the communal dining room with the other residents in care.  This was done in order to assist them with acclimating to their new surroundings. 

According to a review of records, on 02/27/24 at 4:30 PM, one of the Eskaton residents (R1) complained of a sore throat and an inability to swallow. R1's temperature was taken and was recorded as 97.4 degrees Fahrenheit . Hospice was notified.  At 2:00 PM, when the responsible party (F1) was visiting R1, R1 complained of a sore throat again.  F1 requested that R1 be tested for COVID. The med tech on duty denied the request and responded that wasn't policy and that they only tested when symptoms were present.  F1 replied that there were symptoms, i.e. the sore throat.  When the med tech refused to test R1, F1 requested a test kit so that they could test R1.  The med tech provided the test kit.  R1 test positive for COVID. Hospice was notified and the resident was then isolated to prevent the spread of COVID. 

Upon further review of the Plan,this LPA found that the staff at the facility did not follow their mitigation protocols.  Per this plan, on page 5 it stated, for confirmed Covid - 19 cases, "Reported illnesses have ranged from mild symptoms to severe illness and death. Symptoms may appear 2-14 days after exposure to
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240229151350
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: 09/17/2024
NARRATIVE
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the virus. People with these symptoms or combinations of these symptoms may have Covid- 19:
  • Fever or chills
  • Cough
  • Shortness of breath
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea"

On page 40 , number 6 of this plan, it also stated, "Test residents and staff who had known exposure to the individual. Additional testing should be done based on guidance from the health department and the level of exposure."  According to interviews with S2, this was not done; at a minimum, the residents who transferred from Eskaton Village should have all been tested as they previously lived in the same facility and had been grouped together in communal areas after arriving. 

On page 58 of this document it went on to state precautions in memory care specifically:
8. "Suspected or Confirmed cases of COVID-19 - If it is necessary to isolate a resident in memory care due to suspected or known COVID -19, consider these steps in addition to normal COVID-19 policies:
  1. As it may be challenging to restrict residents to their rooms, implement universal use of eye protection and N95 or other respirators (or facemasks if respirators are not available) for all personnel when on the unit to address potential for encountering a wandering resident who might have Covid-19.
  2. Moving residents with confirmed COVID-19 to a designated COVID-19 care unit can help to decrease the exposure risk of residents and staff.
  3. Additionally, at the time a resident with COVID-19 or asymptomatic infection has been identified, other residents and personnel on the unit may have already been exposed or infected, and additional testing may be needed.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240229151350
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: 09/17/2024
NARRATIVE
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d. If due to cognitive impairments it is not possible to isolate the resident, it may be necessary to treat the entire memory care area/unit as isolated. This would include not allowing staff to work in other areas of the community, and implementing droplet/contact precautions throughout the memory care area/unit. "

When this LPA conducted interviews,  5 out of 5 respondents stated that staff were not required to wear masks while working in the memory care communal areas, only upon entering the room of a resident who had been confirmed COVID positive.  

S2, S6, and F1 all stated that R1 would wander out of their room looking for their friend and had the opportunity to come in contact with unmasked residents and staff. 

This LPA learned that Eskaton Gold River did not follow its own Covid-19 Preparedness and Response Plan on multiple occasions.  Residents from Eskaton Village were potentially exposed and were not tested upon move-in.  R1 was not tested for COVID-19 symptoms even though they were complaining of a sore throat. The other residents who had been in close proximity to R1 were not immediately tested for COVID-19, as directed by the Plan.  R1 exhibited wandering behavior when the attempt was made to isolate them.  Masks were not required for staff in the common areas and both residents and staff were potentially exposed to COVID when R1 left their room. 

A total of 6 residents were reported to have tested positive for COVID-19. in the February/ March time frame of this complaint. 

The standard for the preponderance of evidence has been met and the allegation, "Staff did not follow protocols to prevent the spread of illness," has been SUBSTANTIATED.

Regarding: Staff did not assist resident in a timely manner.

R1 should have been tested for COVID-19 upon move-in. They were not.  R1 should have been tested for COVID-19 when they complained of a sore throat. According to interviews both S2 and F1 confirmed that R1's temperature was checked and because it was normal, R1 was told that they were not exhibiting COVID
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240229151350
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: 09/17/2024
NARRATIVE
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symptoms and would not be tested. According to the facility's own Plan,a sore throat is a COVID symptom and testing should have been done. 

The standard for the preponderance of evidence has been met and the allegation, "Staff did not assist resident in a timely manner, has been SUBSTANTIATED.

According to the California Code of Regulations, Title 22, all deficiencies are listed on the LIC 9099 D page.  A copy of this report was provided along with the APPEAL RIGHTS and an exit interview was conducted with the Administrator, Neal Torres.




SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240229151350
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: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
Section Cited
CCR
87405(b)
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Administrator Qualifications
(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.

This requirement was not met as evidenced by:
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Administrator will develop and submit a plan for conducting an inservice on idenitifying COVID symptoms in addtion to reviewing the COVID Preparedness and Response Plan.
The plan for this inservice and an outline
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Based on interviews and records review, the Administrator did not ensure that the COVID-19 Preparedness and Response Plan was implemented. Residents were not tested upon move-in, additional testing was not conducted immediately on those who were in proximity of infected residents, and staff did not wear masks in communal areas. This posed an immediate risk to the heath, safety, and personal rights of residents in care.
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of what it will cover will be submitted to kimberly.viarella@dss.ca.gov by 9/18/24 and the trainings (for all care staff and leadership) will be completed by 10/11/24. Signature sheets will be submitted to CCL at the the aove email address.
Type A
09/18/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental
(a) ... incidental medical and dental care shall be developed by each facility... provide for assistance in obtaining such care ...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Administrator will arrange for an inservice for med techs on personal rights, the date of which will be submitted to CCL at the email above by 9/18/24. The training will be completed by 10/11/24 and signatures sheets will be submitted to CCL at the email above.
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This requirement was not met as evidenced by:
Based on interviews and a review of records, R1 was denied medical assistance when they requested a COVID test. This posed an immediate risk to the health, safety and personal rights of 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6