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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 01/23/2025
Date Signed: 01/23/2025 02:06:17 PM

Document Has Been Signed on 01/23/2025 02:06 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 ROSEVILLEFACILITY NUMBER:
315002052
ADMINISTRATOR/
DIRECTOR:
HILL, ADAMFACILITY TYPE:
740
ADDRESS:1650 ESKATON LOOPTELEPHONE:
(916) 789-7831
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 125TOTAL ENROLLED CHILDREN: 0CENSUS: 90DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Alicia RistTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On 01/23/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced to conduct the annual inspection. LPA met with Interim Executive Director (IED) Alicia Rist and explained the purpose of the visit. Currently there are 90 residents of which 17 residents are receiving hospice care.

LPA toured facility with IED to ensure health and safety of residents in care. LPA toured ten (10) resident rooms, medication room, bathrooms, kitchen, common living spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for two (2) day perishable and seven (7) day nonperishable. LPA reviewed drill logs, which are current.

LPA reviewed ten (10) resident files and ten (10) staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA reviewed four (4) resident medications comparing with current physician orders.

LPA requested facility to send a copy of the current liability insurance.

LPA completed the full care tool and no deficiencies was observed.

Exit interview conducted and a copy of the report was left at the facility.
Laura MunozTELEPHONE: (916) 263-4743
Cheyenne RatajczakTELEPHONE: (916) 969-7879
DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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