<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340313383
Report Date: 09/13/2023
Date Signed: 09/13/2023 04:17:58 PM

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
03/20/2023 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20230320100736
FACILITY NAME:ESKATON VILLAGEFACILITY NUMBER:
340313383
ADMINISTRATOR:KLICK, GREGFACILITY TYPE:
741
ADDRESS:3939 WALNUT AVETELEPHONE:
(916) 974-2000
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:500CENSUS: 412DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Greg KlickTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not adhere to Resident’s special diet.
Facility staff did not provide care and supervision during meals which resulted in resident death.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/13/23, Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced and spoke to Greg Klick, Executive Director, to deliver complaint findings for the above allegation.

The Department reviewed resident records, facility records and conducted extensive interviews.
The Department finds that the allegations cited above are substantiated.

It was determined that on 3/11/23, R1 was provided a meal in their room that contained large pieces of meat. R1 had physician’s orders in place for a mechanical soft diet. Staff, S1, delivered the food to R1’s room and left it unattended while R1 was in the restroom. S1 left the food unattended in order to empty the trash. While S1 was not present, R1 attempted to eat the food which had been delivered, R1 choked on the food left and was found by a medication technician, S2, a short time later. S1 returned to find R1 choking and attended to by S2. CPR was provided and emergency responders were called. Emergency responders found and dislodged a piece of meat from R1’s throat. R1 was transported to an area hospital where they died on 3/15/23 after efforts to treat R1. Cause of death was determined to be due to anoxic cerebral injury, cardiac arrest, and aspiration.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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 6
Control Number 59-AS-20230320100736
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
FACILITY NUMBER: 340313383
VISIT DATE: 09/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
** report amended on 9/27/23**

Records and statements found that R1 was admitted to this facility on 2/21/23. R1 had a physician’s report (LIC 602) at admission, dated 9/16/22. The 9/16/22 LIC 602 stated that R1 had Parkinson’s disease, cognitive issues, no special diet and hand written notes on the LIC 602 that R1 needs help cutting food.
On ** 2/21/23, the facility received a physician’s order for R1’s food to be chopped in general and an order of a mechanical soft diet. (The University of Toledo describes a mechanical soft diet as- Level 2: consists of foods that are moist, soft-texture, and easily swallowed. Meats are ground or finely cut to equal size no bigger than ¼ inch. Or Level 3: includes food that is nearly normal excluding very hard, sticky, or crunchy foods. Foods should not be overly dry and should still be moist and bite sized. https://www.utoledo.edu/depts/csa/caringweb/softdiet.html).
The licensee provided records to the investigator that on 3/29/23 training was provided to food service staff regarding Textured Modified Diets and Thickened Liquids that identify a mechanical soft diet for meats to be served ground and moistened with gravy or sauce.

The Resident Functional Evaluation provided to the Department for R1, dated 2/21/23 notes R1 requires reminders for eating rather than alternative designation of Needs assistance in cutting food or supervision during meals. A second Resident Functional Evaluation form was submitted, however, it did not identify a resident or evaluator, but identifies resident preferred name of an abbreviation of R1’s name. In this form it is noted: Special diet- Chopped, Types of assistance- cutting of meat, and Eating- Has eating or swallowing difficulties requiring complete assistance and supervision during meals.
The resident assessments were reviewed and approved, on a RCFE Assisted Living Prospective Resident Approval Review form, by Assistant Executive Director, Ryan Nakao, Residential Living Advisor, Shanti Willis and Resident Care Coordinator, Chantel Krahn.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20230320100736
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
FACILITY NUMBER: 340313383
VISIT DATE: 09/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff interviews and records indicated that on 3/11/23, Kitchen Supervisors, S3 and S4, were managing food service. The resident’s food was to be prepared and packaged for R1 to receive in their room. S3 and S4 failed to adhere to the Dietary/ Nursing Communication which was posted for R1. The Aforementioned communication designated R1’s diet of Solids- Mechanical Soft Chopped & Bite Sized. Instead, on 3/11/23, Kitchen Supervisors prepared R1’s meal to include three (3) pieces of meat that were not chopped nor bite sized. The food was placed in a Styrofoam container with a lid and placed in a plastic bag.

S3 and S4 were subsequently terminated on 3/24/23 after the licensee completed their internal investigation. For both S3 and S4, the termination letters noted: “…you did not and have not consistently provided supervision necessary to ensure that residents who required special diets actually received them. As a result, multiple residents have received food that was not appropriately prepared for them in accordance with their dietary orders, placing them at risk.”

Interviews and records review found that on 3/11/23, at approximately 5:25 PM, caregiver S1 delivered the packaged meal to R1’s room. In a statement, S1 stated that she was unaware of R1’s dietary restrictions and had not been instructed to examine the contents of R1’s meal prior to delivering the meal to R1’s room. S1 acknowledged during interview that S1 left the food unattended in order to empty the trash. While S1 was not present, R1 attempted to eat the food which was delivered, choked and was found by a medication technician, S2, a short time later.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20230320100736
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
FACILITY NUMBER: 340313383
VISIT DATE: 09/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The Department’s review of meal preparations procedures in place on 3/11/23 found that S3 and S4 were responsible to ensure that residents’ food be reviewed for quality and dietary accuracy before it is released for delivery to residents. The licensee’s and the Department’s investigations found that S3 and S4 failed to prepare R1’s diet properly and failed to review R1’s food before being packaged for delivery. Procedures did not contain provisions for caregiver review of food and diet when food was to be delivered by staff, as in the case of R1 who was required to remain in their room under quarantine. Therefore, S1 was unaware of R1’s diet restrictions and the contents of the meal when S1 left R1 unattended and R1 was able to access the meal.

This procedural oversight resulted in R1 lacking proper supervision and assistance with their meal, consuming improperly prepared food, choking, hospitalization and eventual death.

In addition to the failure on the parts of S3 and S4 to properly prepare the food for R1 on 3/11/23, the investigation also found: S3’s and S4’s incidents of, as their terminations letters state- “multiple residents have received food that was not appropriately prepared”- had not been addressed in supervisor action prior to the incident on 3/11/23; that the procedures in place did not address individual meal verification when delivered to resident rooms; and that S1 was not provided appropriate training regarding R1’s dietary needs and assistance with cutting food.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230320100736
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
FACILITY NUMBER: 340313383
VISIT DATE: 09/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident death while in care at this facility.
As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.

Report reviewed with Executive Director . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20230320100736
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
FACILITY NUMBER: 340313383
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2023
Section Cited
CCR
87555(b)(7)
1
2
3
4
5
6
7
General Food Service Requirements (b)(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
This requirement was not met based on records and statements that resident was not served a special diet as ordered a physician.
1
2
3
4
5
6
7
Policies have been updated and training provided. Licensee will submit a statement that that they will submit an policy to their plan of operations for food service special diets that includes review of food deliveries to resident rooms will be completed by 9/18/23.

8
9
10
11
12
13
14
This posed an immediate risk to the resident's health and safety.
8
9
10
11
12
13
14
The addendum will include training of all staff, communication between all staff and checking of correct meals to be served to residents- including for those residents receiving food in their rooms.
Type A
09/18/2023
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
Basic Services (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating… This requirement was not met based on records review, interviews and a resulting death of a resident. Evidence
1
2
3
4
5
6
7
Training and communications have been updated. Licensee will submit proof of polices and training for ensuring resident care needs and dietary needs are known to caregivers and food service employees by the POC date of 9/18/23
8
9
10
11
12
13
14
found resident was not provided identified eating assistance.
This posed an immediate risk to resident's health and safety.
8
9
10
11
12
13
14
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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6