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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097005046
Report Date: 12/08/2025
Date Signed: 12/08/2025 11:39:31 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
11/13/2025 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20251113150027
FACILITY NAME:ESKATON VILLAGE PLACERVILLEFACILITY NUMBER:
097005046
ADMINISTRATOR:TIBURCIO, MELISAFACILITY TYPE:
740
ADDRESS:3380 BLAIRS LNTELEPHONE:
(530) 295-3400
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:74CENSUS: 48DATE:
12/08/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Melisa TiburcioTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Licensee did not ensure staff met criminal record clearance requirements prior to working at the facility.
INVESTIGATION FINDINGS:
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On December 8, 2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Administrator Melisa Tiburcio. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on documents obtained facility did not ensure that a criminal record clearance was obtained for S1 in 2022, when S1 was working at the facility. Record review indicated that S1 started working on April 13, 2022, and did not get the fingerprint clearance until February 2, 2023, which poses an immediate health, safety, or personal rights risk to persons in care. The preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Immediate civil penalty of $500.00 was issued today. Failure to correct shall result in civil penalties.

Appeal Rights given to administrator. A copy of this report has been provided to facility. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
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 59-AS-20251113150027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESKATON VILLAGE PLACERVILLE
FACILITY NUMBER: 097005046
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2025
Section Cited
CCR
87355(e)(2)
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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department (...). This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding criminal background clearances and ensure that staff obtain a criminal background clearance before providing services to residents. Facility will submit statement to LPA by POC due date.
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Based on records reviewed, facility did not ensure that a criminal record clearance was obtained for S1, which poses an immediate health, safety or personal rights risk to persons in care.
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A civil penalty in the amount of $500 was assessed for today's date regarding staff not having a criminal background clearance in 2022.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2