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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001241
Report Date: 06/01/2022
Date Signed: 06/01/2022 11:33:53 AM


Document Has Been Signed on 06/01/2022 11:33 AM - 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: 65DATE:
06/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jocelyn Perena, ManagerTIME COMPLETED:
11:45 AM
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On 6/1/22 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to ensure the health and safety of residents and address additional questions regarding the death of R1. LPA met with staff Jocelyn Perena to get additional information regarding the death of a resident.

LPA Gould conducted file review for former resident and conducted interviews with two staff members to get additional information regarding the former resident and and to obtain additional information leading up to his death and the actions of the facility immediately after resident was found unresponsive. LPA could not interview staff who first discovered R1 as she is on on leave at the time of inspection.

Based on the interviews, information gathered, and documentation reviewed there were no deficiencies assessed at the time of inspection.

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: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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