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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001241
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:17:29 PM

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: 59DATE:
08/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Neal TorresTIME COMPLETED:
02:30 PM
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On 8/20/21 at 1:15pm LPA Gould made an unannounced Case Management inspection to address concerns regarding an incident report dated 8/13/21 involving an altercation between two residents. LPA and Administrator discussed mitigation measures taken after the incident including enhanced staffing and medication changes and observations. LPA Gould conducted interviews with three staff members on duty at the time of the alleged incidents.

LPA Gould was informed the facility has requested video documentation to be obtained by facility and will be provided to LPA. Department advises to continue to monitor resident's interactions and for changes in behavior. If there is another reoccurrence of the same nature the department will require residents be reassessed by their physician to determine if the current placement continues to be appropriate.

Based in the interviews conducted and LPAs observations there are no deficiencies observed or cited during todays inspection. A copy of this report was 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: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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