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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005046
Report Date: 08/08/2023
Date Signed: 08/08/2023 01:57:03 PM


Document Has Been Signed on 08/08/2023 01:57 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ESKATON VILLAGE PLACERVILLEFACILITY NUMBER:
097005046
ADMINISTRATOR:MCGRATH, EVELYNFACILITY TYPE:
740
ADDRESS:3380 BLAIRS LNTELEPHONE:
(530) 295-3400
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:74CENSUS: 57DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Evelyn McGrathTIME COMPLETED:
02:20 PM
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On 08/08/2023, Licensing Program Analysts (LPAs) Ivan Avila and Lavinia Muscan, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPAs met with Facility Administrator Evelyn McGrath and explained the purpose of the visit.

LPAs and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, hallways, common restrooms, and outside area. LPAs observed the facility to be clean, in good repair and odor-free. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked.The hot water temperature measured within the required range of 105-120 degrees. LPAs observed facility's fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPAs reviewed a total of five (5) residents' files and five (5) staff files.

There were no deficiencies cited at this time.

An exit interview was held, and a copy of the report was provided to Administrator Evelyn McGrath.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
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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