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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001275
Report Date: 06/06/2022
Date Signed: 06/06/2022 11:34:54 AM


Document Has Been Signed on 06/06/2022 11:34 AM - 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ESKATON LODGE CAMERON PARKFACILITY NUMBER:
097001275
ADMINISTRATOR:LAL, PRIYAFACILITY TYPE:
740
ADDRESS:3421 PALMER DRTELEPHONE:
(530) 672-8900
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:60CENSUS: 32DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Elaine Brattin, Business Services ManagerTIME COMPLETED:
11:53 AM
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On June 6, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived to conduct a 1 year required annual inspection. LPA met with Elaine Brattin, Business Services Manager and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the Personal Protective Equipment (PPE) was worn: mask. Additionally LPA was screened by front desk personnel. The Administrator Certificate expires July 20, 2023.
Elaine and LPA conducted the infectious Control questionnaire with no issues to report.

There are 47 rooms for residents. Rooms had the required items of furniture. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. Smoke alarms and fire extinguishers are in good condition. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food.

No Deficiencies observed or cited during this visit.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than July 6, 2022.

Exit interview with Elaine. A copy of this report was left with Elaine.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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