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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005590
Report Date: 02/01/2024
Date Signed: 02/02/2024 05:49:06 PM


Document Has Been Signed on 02/02/2024 05:49 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
02/01/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jenilyn Tabaco and Diana ReitzTIME COMPLETED:
11:30 AM
NARRATIVE
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Unannounced Plan of Correction visit was made out to this facility on 02/01/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff, Jenilyn Tabaco and Diana Reitz, who were requested by this LPA to go ahead and contact the facility designated Administrator, Rick Reed, at this time.
A brief interview was conducted with the facility designated Administrator over the telephone at this time.
Current census was 15 residents.
Brief interviews were also conducted with facility staff who were present at this time.

The purpose of plan of correction visit was to follow up on deficiencies that were observed and cited on a prior visit, conducted on 12/21/2023, for the following:

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.
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.

This deficiency is being recited since this LPA has not received any corrections from this facility and its representative.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was left with the facility staff 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: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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 2


Document Has Been Signed on 02/02/2024 05:49 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
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: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2024
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: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2