347001241-3-4-2022-27-AS-KHOS-CCJHX5-20220315063431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 02/24/2022
Date Signed: 03/04/2022 03:59:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20211025152643

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:	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Neal Torres		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
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5
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8
9

Personal Rights:
1) Facility did not seek timely or adequate medical attention for resident's injury.

INVESTIGATION FINDINGS:

1
2
3
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5
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7
8
9
10
11
12
13

This is an amended report to correct LPA error of unfounded complaint findings regarding the allegation: Resident was attacked by another resident resulting in serious injury. Although R1 did not sustain any injuries as a result of an aggressive act by R2, LPA incorrectly determined the entire allegation was unfounded which misrepresents LPA's investigation which clearly finds that R1 was assaulted by R2.

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Eskaton Gold River Lodge (RCFE) on 2/24/22 at 9:45am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

The allegation that R1 did not receive timely or adequate medical attention cannot be corroborated. LPA conducted interviews with S1 and A1 who both confirmed R1 went to the hospital on the day of the reported incident and was met at the hospital by family who advocated for additional testing including CT head scans, and x-rays of arms, legs and hip which was corroborated by A1. A1 also confirmed R1 received a follow up evaluation by her primary care physician.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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-20211025152643

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LODGE	FACILITY NUMBER: 347001241
	VISIT DATE: 02/24/2022

NARRATIVE

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This is an amended LIC 9099-C and a continuation of the previously amended report.

The Department has investigated the complaint alleging Personal Rights. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20211025152643

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:	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Neal Torres		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Other: Facility did not disclose pertinent information to responsible party about resident's injury.
Personal Rights: Resident was attacked by another resident resulting in serious injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 27-AS-20211025152643

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LODGE	FACILITY NUMBER: 347001241
	VISIT DATE: 02/24/2022

NARRATIVE

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This is an amended LIC 9099-C and a continuation of the previously amended report.

Based on interviews with S1, A1 and RP and records review for R1. LPA was unable to corroborate the facility did not disclose pertinent information regarding the incident between R1 and R2 to R1's family. based on the interviews conducted the facility conducted additional investigation after locating R1 on the ground believing it to be a fall. facility staff reviewed video evidence and determine there was an aggressive act by R2 against R1. LPA was unable to clearly determine what had been disclosed to family and at what time due to the evolving nature of the facility investigation into R1's fall which evolved to an aggressive act by another resident upon further investigation.

Based on the interviews conducted and statements obtained during the investigation process, the allegations cannot be corroborated because R1 (see confidential name list LIC-811 dated 2/24/22) did not receive any injuries as a result of the altercation with R2. Although the department has determined that R2 did initiate an aggressive act against R1, medical records from R1's discharge from the hospital and subsequent follow up with R1's primary care physician did not reveal any serious injuries to R1. This was corroborated by R1's medical records documentation and statements obtained from interviews with A1 and S1.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20211025152643

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:	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Neal Torres		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/Lack of Supervision: Facility did not maintain adequate staffing to meet resident's needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Eskaton Gold River Lodge (RCFE) on 2/24/22 at 9:45am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated because R1 (see confidential name list LIC-811 dated 1/24/22) was the victim of an aggressive act by R2. In observing a video recording of the incident captured by facility cameras, LPA observed several aggressive acts by R2 against R1. Due to the history of aggression by R2 documented by he facility and the duration of the aggressive act with no staff intervention LPA was able to corroborate the allegation. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 27-AS-20211025152643

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LODGE	FACILITY NUMBER: 347001241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/25/2022 Section Cited HSC 87411(a)	1 2 3 4 5 6 7	Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports.	1 2 3 4 5 6 7	Facility will provide the department with a written plan for routine surveillance and ensuring as staff presence and monitoring of residents to prevent further instances from reoccurring at the facility.
	8 9 10 11 12 13 14	Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by LPAs observation of camera recordings of the incident between R1 and R2 in a common area of the memory care unit where no staff were present to intervene and meet the needs of the resident which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 03/04/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by multiple acts of aggression by R2 against R1 documented by the facility which poses a potential health and safety risk to residents in care.	1 2 3 4 5 6 7	Facility will provide the department with a written plan to address the steps facility will take to ensure resident safety when a resident displays an act of aggression towards another resident.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 6