315002052-2-19-2026-59-AS-TORZ-DRP27T-20260226160916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002052
Report Date: 02/19/2026
Date Signed: 02/19/2026 03:10:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/16/2026 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20260116142539

FACILITY NAME:	ESKATON VILLAGE ROSEVILLE		FACILITY NUMBER:	315002052
ADMINISTRATOR:	STEPHEN MACDONALD		FACILITY TYPE:	740
ADDRESS:	1650 ESKATON LOOP		TELEPHONE:	(916) 789-7831
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	125	CENSUS: 81	DATE:	02/19/2026
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Stephen MacDonald, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff neglect led to resident's injury
Staff did not provide a safe environment for residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Administrator Stephen MacDonald during today’s inspection.

LPA investigated allegation, “Staff neglect led to resident's injury”. LPA interviewed relevant parties, residents, and staff and reviewed resident documentation. Relevant party (RP) stated R1 was admitted into the facility and staff were aware that R1 was a smoker and R1 was told they could smoke in the gazebo near the front entrance. Few days into their stay at the facility, R1 was told they would need to move to the smoking area at the back of the building. There was a back exit near R1’s apartment, however RP stated the door was too heavy for R1 to use. In December 2025, R1 attempted to exit the building on their own and hurt their back. R1 was seen in the hospital and was diagnosed with a compression fracture of the spine. Relevant party stated that staff should not have provided a smoking area that was not safe for R1 to access.
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260116142539

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ESKATON VILLAGE ROSEVILLE	FACILITY NUMBER: 315002052
	VISIT DATE: 02/19/2026

NARRATIVE

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LPA interviewed administrator in which they stated they did not inform R1 that they could smoke in the gazebo area as it is against state law to smoke that close to the building entrance. Administrator stated that they did provide an alternative area for resident to smoke safely at. Administrator stated residents were not receiving any care at the time of the incident. LPA reviewed resident’s documentation which shows resident has a history of osteoporosis and other health related diagnosis. LPA reviewed hospital documentation from the visit following the incident in which it states resident was diagnosed with a spinal fracture. Due to the information gathered, LPA is unable to determine if staff neglect led to residents injury. Allegation is found to be UNSUBSTANTIATED.

LPA investigated allegation, “Staff did not provide a safe environment for residents in care”. LPA interviewed relevant parties, residents, and staff and reviewed resident documentation. Relevant party stated R1 is a smoker and was told they would need to move to the smoking area at the back of the building. Relevant party stated in order to get to the smoking area from the back exit, R1 had to either step down from the curb onto the parking lot or use a ramp which had obstructions and tripping hazards. Relevant party showed LPA photos of a hose near the ramp and other boxes which could cause a tripping hazard. The smoking area was eventually moved to a different location in the front of the building that had coverage and more accessible for R1. LPA toured the facility and observed where the past smoking area was located and LPA did not see any obstruction or tripping hazards present. LPA reviewed R1’s documentation in which it states resident is non-ambulatory due to the use of a walker and has macular degeneration. Due to the information gathered, LPA was unable to determine if staff did not provide a safe environment for residents in care. Allegation is UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

LIC9099 (FAS) - (06/04)

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