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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005590
Report Date: 04/07/2023
Date Signed: 04/07/2023 01:35:52 PM


Document Has Been Signed on 04/07/2023 01:35 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: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:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rick ReedTIME COMPLETED:
01:45 PM
NARRATIVE
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On 4/7/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Rick Reed and explained the purpose of today's visit.

LPA Jensen toured the grounds and interior of the facility. The grounds were well maintained and all paths were free of debris. The facility was observed to be sanitary and free of odor. All rooms in the facility were adequately furnished. The facility maintains a variety of activities for resident engagement. There are animals throughout the property that residents enjoy caring for. Lunch service was observed and consisted of BBQ ribs removed from the bone with beans and sweet potatoes and fruit punch to drink. For dinner the facility is celebrating a resident birthday and will be serving decorated cupcakes for dessert. The facility maintains in excess of a 2 day supply of perishable food and 7 day supply of non-perishable food. The water temperature in the women's bathroom between bedroom 3 and 5 measured at 97 degrees at the highest reading which falls outside of the required range of 105-120 degrees Fahrenheit. The water temperature was measured both upon arrival and before leaving. The thermostat was set at 75 degrees which falls within the required range of 68-85 degrees Fahrenheit. The fire extinguisher and carbon monoxide detector were in compliance. The first aid kit was complete and in compliance.

All staff were determined to be associated to the facility and have criminal background clearance. LPA Jensen interacted with several residents and conducted interviews. The inspection tool was used during the course of this visit. The inspection tool was used during the course of this visit.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted a copy of this report and appeal rights were given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 04/07/2023 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ESCALON SENIOR ESTATE
FACILITY NUMBER: 397005590

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's check of the water temperature, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
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Licensee agrees to adjust water temperature and email a log of temperature checks conducted for 7 consecutive days by Plan of Correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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