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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005590
Report Date: 12/21/2023
Date Signed: 01/09/2024 04:59:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231107142723
FACILITY NAME:ESCALON SENIOR ESTATEFACILITY NUMBER:
397005590
ADMINISTRATOR:RICK REEDFACILITY TYPE:
740
ADDRESS:16460 S. ESCALON BELLOTATELEPHONE:
(209) 838-0888
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:15CENSUS: 15DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jenilyn Tabaco and Diana ReitzTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff have not repaired the facility grounds

Staff do not keep the facility free from rodents

Staff do not ensure the facility water is consumable for the residents
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 12/21/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff, Jenilyn Tabaco and Diana Reitz, who were briefly interviewed. This LPA requested that facility staff go ahead and contact the facility designated Administrator, Rick Reed, to inform him that CCL was present at this time. The facility designated Administrator was unable to come to this facility during today's complaint visit.
Current census was 15 residents.
The purpose of this visit was to deliver the findings of this complaint investigation to the facility and its representatives at this time.
Based on a brief tour of this facility and the exterior grounds, it was observed that there were not any items that were in need of repair/replacement at this time. A review of the facility perimeter fence and side gates were also conducted.
Based on interviews conducted, it was learned that the water dispenser that was stationed in the hallway was open for use by all facility residents. This water dispenser was used by the residents to obtain water to
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231107142723

FACILITY NAME:ESCALON SENIOR ESTATEFACILITY NUMBER:
397005590
ADMINISTRATOR:RICK REEDFACILITY TYPE:
740
ADDRESS:16460 S. ESCALON BELLOTATELEPHONE:
(209) 838-0888
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:15CENSUS: 15DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jenilyn Tabaco and Diana ReitzTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are serving expired food to the residents
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 12/21/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff, Jenilyn Tabaco and Diana Reitz, who were briefly interviewed. This LPA requested that facility staff go ahead and contact the facility designated Administrator, Rick Reed, to inform him that CCL was present at this time.
The facility designated Administrator was unable to come to this facility during today's complaint visit.
Current census was 15 residents.
The purpose of this visit was to deliver the findings of this complaint investigation to the facility and its representatives at this time.
Based on a review of the facility food supply for 2-day perishable and 7-day nonperishable quantities, it was observed that certain food items were found to be expired and needed to be discarded and replaced.
The expired food items were brought to the attention of the facility staff persons who were present at this time.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231107142723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESCALON SENIOR ESTATE
FACILITY NUMBER: 397005590
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87555(b)(8)
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The following food service requirements shall apply:
All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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The facility representative stated that an audit of all facility perishable and nonperishable quantities will be conducted. Any, and all, food items that are expired and no longer of good quality will be discarded and no longer used for the residents.
A statement of correction will be completed
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The facility did not meet the needs of this requirement as evidenced by the presence and continued use of food items which were expired and not of good quality at this time. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.
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in regards to this food audit with submission into CCL by the due date.
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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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231107142723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ESCALON SENIOR ESTATE
FACILITY NUMBER: 397005590
VISIT DATE: 12/21/2023
NARRATIVE
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As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility representative at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231107142723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ESCALON SENIOR ESTATE
FACILITY NUMBER: 397005590
VISIT DATE: 12/21/2023
NARRATIVE
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drink on hot days if necessary. This water dispenser was observed to be functional and able to meet the needs of the residents at this time. Based on interviews, the facility residents were content with the water dispenser at this time.
Based on interviews conducted, it was learned that there weren't any sightings of rodents inside of this facility at this time. A brief tour of the facility kitchen and common areas was conducted and this LPA did not observe any signs of rodents or pests at this time.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5