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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001275
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:25:13 PM


Document Has Been Signed on 05/15/2023 02:25 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 33DATE:
05/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:VP Residential Services Tighe HammamTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on Monday May 15, 2023 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (6) and staff (5) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA and Maintenance Director Tom Noftsier toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, kitchen, hallways, bathrooms, dining room/kitchen, common areas and outside areas. Water temperatures in the apartments toured were within the required range of temperature. LPA observed the facility's emergency food and water storage and PPE storage. In the areas toured, there were no health or safety violations observed.

LPA reviewed fire drills. All required postings were observed in the lobby area.

LPA requested the facility to send updated LIC500 via email to CCLD.

No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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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