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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297001933
Report Date: 07/10/2025
Date Signed: 07/10/2025 11:53:01 AM

Document Has Been Signed on 07/10/2025 11:53 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ESKATON VILLAGE GRASS VALLEYFACILITY NUMBER:
297001933
ADMINISTRATOR/
DIRECTOR:		ALICIA RISTFACILITY TYPE:
740
ADDRESS:625 ESKATON CIRTELEPHONE:
(530) 273-1778
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 160CENSUS: 124DATE:
07/10/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Alicia Rist, Executive Director (ED)TIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Alicia Rist, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on July 7, 2025.

On July 7, 2025, the Department received an SIR indicating that, on July 5, 2025, staff were unable to locate resident (R1) on the premises after attempting to escort R1 to breakfast. SIR states that facility initiated elopement protocols after determining that R1 was not on the premises, including contacting R1's responsible party (RP), local law enforcement, and local hospital. RP was able to reach R1 via cell phone. R1 was located at their residence and escorted back to the community via facility staff. R1 was last seen in their apartment at 7:34 PM on July 4, 2025. R1 exited their apartment at 7:42 PM on July 4, 2025. R1 was picked up at their residence at approximately 10:30 AM on July 5, 2025 after locating R1. R1's residence is located approximately five (5) miles away from the community. Facility identified that wanderguard for R1 did not function as intended and maintenance repaired wanderguard after incident. Facility also identified cameras within the community did not cover certain exits in which R1 could have exited the community. Camera coverage throughout the community is being evaluated and rectified. SIR indicates that R1's care plan is being updated and family will arrange for additional hours for 1:1 companionship for R1. R1's Medical Assessment LIC 602A dated June 26, 2025, indicates that R1 has Mild Cognitive Impairment (MCI). R1's LIC 602A states that R1 is not able to leave the facility unsupervised with a note stating, "has memory problems and need to be supervised at the beginning. [R1] can leave the apartment but can not leave the facility unsupervised."

** Report continued on 809-C **
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 GRASS VALLEY
FACILITY NUMBER: 297001933
VISIT DATE: 07/10/2025
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As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87464(f)(1) regarding Basic Services in relation to care and supervision. The deficiency is listed on 809-D.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/10/2025 11:53 AM - It Cannot Be Edited


Created By: Michael Hood On 07/10/2025 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESKATON VILLAGE GRASS VALLEY
FACILITY NUMBER: 297001933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2025
Section Cited
CCR
87464(f)(1)

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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
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Facility repaired resident's wanderguard and will be evaluating placement of community cameras. Facility conducted an in-service training with staff regarding elopement protocols and wanderguard response.
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Based on records reviewed, the facility did not ensure that resident R1 was properly supervised, resulting in AWOL, which poses a potential health, safety, and personal rights risk to residents in care.
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Facility will submit proof of training to LPA by POC due date 7/16/25.

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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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
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