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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002052
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:57:03 PM

Document Has Been Signed on 01/17/2025 03:57 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 ROSEVILLEFACILITY NUMBER:
315002052
ADMINISTRATOR/
DIRECTOR:		HILL, ADAMFACILITY TYPE:
740
ADDRESS:1650 ESKATON LOOPTELEPHONE:
(916) 789-7831
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 125CENSUS: DATE:
01/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Tricia Diaz, LVN RCCTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 1/17/2025, Licensed Program Analyst (LPA) Cassandra Mikkelson and Licensed Program Manager (LPM) Laura Munoz arrived at the facility to conduct a case management visit regarding two (2) LIC 624 reports sent to CCL.

The facility sent the department an LIC 624 on 01/07/2025 which stated that R1 was sent to the hospital on 12/30/2024 for shortness of breath. Family contacted the facility on 01/06/2025 to report R1 passed away due to pneumonia. A review of R1's LIC602/physician's report indicated R1 had a diagnosis of COPD and respiratory failure. R1's needs and service plan and physician orders indicated R1 was on oxygen at bedtime. Staff indicated R1 would be seen walking around the facility with their oxygen regularly. Based on the documentation reviewed and interviews conducted, no further follow up is needed at this time.

The facility sent the department an LIC 624 on 01/03/2025 which stated that resident R2 was given the wrong dose of Omeprazole. LPA and LPM spoke with Tricia Diaz, LVN RCC, she stated that R2 was originally taking medication two times daily but their physician changed the order to one time daily in October 2024. Per Ms. Diaz facility received order but did not update in their Medication Administration Records (MAR). Medication error was found while attempting to refill medication in December 2024. Facility staff confirmed that R2 was administered the wrong dosage of Omeprazole for approximately three (3) months.

Deficiency is being cited on LIC809-D. Failure to correct plan of correction could result in assessed civil penalties.

Exit Interview and appeal rights provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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Document Has Been Signed on 01/17/2025 03:57 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 01/17/2025 at 03:16 PM
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 ROSEVILLE
FACILITY NUMBER: 315002052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
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The facility shall submit a plan that addresses charting and documenting medication changes timely. Staff shall be trained on the implemented plan. Plan of correction shall be submitted by 01/31/2025.
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This regulation has not been met as evidenced by: Facility staff failed to ensure R2’s medication dosage was correctly documented resulting in R2 being administered the wrong dosage for 3 months which posses a potential health risk to residents in care.
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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.
SUPERVISOR'S NAME:Laura Munoz
LICENSING EVALUATOR NAME:Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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