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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001241
Report Date: 09/09/2021
Date Signed: 09/09/2021 11:44:29 AM

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:
09/09/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Neal TorresTIME COMPLETED:
12:00 PM
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On 9/9/21 at 10:00am LPA Gould made an announced, follow up Case Management inspection to address concerns regarding an incident report dated 8/13/21 involving an altercation between two residents.

LPA met with administrator and together viewed the video footage obtained in common areas in the facility that showed three interactions between two residents with one being the aggressor against the other. Administrator showed that once R1 was assessed and sent to the emergency room for evaluation, they reviewed footage and observed the aggressive behavior from R2. Nurses and administrator obtained earlier footage of reported falls by R1 which indicated R1 was pushed down by R2. Both residents suffer from dementia and receive services in the memory care unit of the facility.

Administrator reported the incident to licensing immediately and submitted SOC 341 concerning elder abuse. Administrator states that R2 will be leaving the facility on 9/9/21, has been assessed for several facilities and are awaiting antigen testing results so that move in can be completed. Facility put enhanced staffing measures in place and worked with R2's physician to adjust medications and ensure all resident's safety.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and 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: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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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