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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001241
Report Date: 03/04/2022
Date Signed: 03/04/2022 03:47:00 PM


Document Has Been Signed on 03/04/2022 03:47 PM - It Cannot Be Edited

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: DATE:
03/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lyn Navarro PerenaTIME COMPLETED:
04:15 PM
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On 3/4/22 at 1:30pm Licensing Program Analyst (LPA) Kevin Gould arrived at Eskaton Gold River Lodge for the purpose of conducting a Case Management Inspection to ensure S1 was no longer working at the facility as the department has received an Immediate Exclusion for S1. LPA met with Business Office Manager Lyn Navarro Perena.

LPA Gould informed the facility of S1's immediate exclusion and requested a current copy of the facility personnel Report (LIC 500). LPA observed S1 is not on the current facility roster. Facility provided LPA with documentation S1 worked at the facility for a short time in 2019 with their last day on 9/4/2019.

As the employee is no longer working at the facility LPA requested the facility disassociate S1 from the facility via guardian.

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: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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