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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003574
Report Date: 10/02/2020
Date Signed: 10/02/2020 02:31:02 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 FOUNTAINWOOD LODGEFACILITY NUMBER:
347003574
ADMINISTRATOR:DESTOUT (BARKER), DAVINAFACILITY TYPE:
740
ADDRESS:8773 OAK AVETELEPHONE:
(916) 988-2200
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:136CENSUS: 52DATE:
10/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Davina Barker, Executive DirectorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Wolter contacted facility Executive Director (ED) Davina Barker via telephone due to COVID-19 and precautionary measures on 10/02/2020, LPA explained the purpose of the call was to discuss an Incident Report (LIC 624) Community Care Licensing (CCL) received on 10/01/2020.

LIC 624 disclosed an incident that occurred with a resident (R1) and a staff (S1) member on or about 09/16/2020 that was brought to EDs attention on 10/01/2020. R1 became combative with S1 during caregiving and S1 was overheard by another staff (S2) making an inappropriate comment in the hallway after the event, the comment was not said to R1 nor did R1 hear the comment. Upon learning about the incident ED conducted an internal investigation and S1 was suspended.

LPA and ED discussed the next steps going forward, either S1 will be let go after the suspension or will be placed on a written final. Should S1 return to work ED has stated that S1 will be re-trained on caregiving and using the proper approach when working with residents with a dementia diagnosis. ED agreed to inform LPA of the outcome.

No deficiencies are being cited as a result of this televisit.

Exit interview conducted and copy of report emailed to ED. ED to sign and return a copy to CCL either by email or fax, signed copy should also be retained for facility records.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
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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