397005590-4-10-2024-27-AS-KHOS-D4DKJH-20240416075646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005590
Report Date: 04/03/2024
Date Signed: 04/10/2024 05:14:16 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
01/30/2024 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240130095431

FACILITY NAME:	ESCALON SENIOR ESTATE		FACILITY NUMBER:	397005590
ADMINISTRATOR:	RICK REED		FACILITY TYPE:	740
ADDRESS:	16460 S. ESCALON BELLOTA		TELEPHONE:	(209) 838-0888
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	15	CENSUS: 14	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Well Tabaco and Rick Reed		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is in disrepair

Staff did not ensure facility is kept free of pests

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unannounced complaint visit made out to this facility on 04/03/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Well Tabaco who was briefly interviewed at this time.
Current census was 14 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility and its representatives at this time.
Based on observation from touring this facility, it was observed that the facility was functioning and being maintained to be able to meet the needs of the residents at this time.
The facility resident bedrooms were maintained with adequate furniture and furnishings to be able to meet the needs of the residents at this time.
The facility resident restrooms were observed to contain the required grab bars and non skid mats. Faucets and showers were observed to be functional and in good repair at this time.
The hot water was measured and observed to be within the allowed range of 105-120 degrees with a

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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 2

Control Number 27-AS-20240130095431

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: 04/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

functioning hot water heater at this time.
Based on observation from touring this facility's interior and exterior grounds, there were no signs of pests at this time. A review of the resident window sills and closets was conducted.
A review of the exits in/out of this facility was conducted.
A tour of the facility kitchen area was conducted. It was observed that there weren't any risks from pests for food contamination through improper storage of food items at this time.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations 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 during today's complaint visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2