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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001241
Report Date: 06/11/2024
Date Signed: 06/11/2024 05:35:56 PM

Document Has Been Signed on 06/11/2024 05:35 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ESKATON GOLD RIVER LODGEFACILITY NUMBER:
347001241
ADMINISTRATOR/
DIRECTOR:		NEAL TORRESFACILITY TYPE:
740
ADDRESS:11390 COLOMA RDTELEPHONE:
(916) 852-7900
CITY:GOLD RIVERSTATE: CAZIP CODE:
95670
CAPACITY: 134CENSUS: 87DATE:
06/11/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Neal TorresTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 6/11/24, Licensing Program Analyst (LPA) Kimberly Viarella arrived at this facility to continue the annual inspection. LPA identified herself upon arrival, stated the purpose of her visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Neal Torres and a brief meeting followed. LPA provided materials to assist with future file reviews.

LPA then returned to reviewing staff files to ensure proper background clearances, health checks and training were all in compliance. LPA reviewed 4 resident files. All were complete and up-to date at the present time.

LPA observed that the DFA's certificate (# 6032067740) expires on 01/02/2025 and was in compliance at the time of the visit.

LPA reviewed 3 staff files and found that they were missing annual training. In 2 of 3 files, the files did not contain the required number of annual hours of training and the training did not include the name and credentials of the trainer or the regulations that the training pertained to. 2 out of 3 were Medication Assistants but the training logged and presented did not include annual medication training. 1 of the 3 staff files did not meet the annual training requirements and had repeated course content listed.

The DFA produced a binder with in-services that were conducted and signature sheets of attendees, however, these did not meet regulation requirements. The DFA also produced an excel spreadsheet to demonstrate that training was implemented, however, the log sheet did not include the duration of the trainings, the trainer, or specific content. It also did not include the topics required as mandatory for annual training. LPA provided technical assistance and handouts which referred to the regulation requirements in order to assist the DFA in establishing a more efficient system for implementing and tracking required trainings.


SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ESKATON GOLD RIVER LODGE
FACILITY NUMBER: 347001241
VISIT DATE: 06/11/2024
NARRATIVE
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As part of this annual inspection the LPA visited 2 of the 4 medication rooms at this facility, one in memory care and the main one in assisted living. LPA inspected med carts, checked for expired medications and reviewed dosing, storage, destruction, and PRN procedures with the Medication Assistants in each area.

LPA tested the response time for staff on two occasions in different parts of the facility. LPA activated the pull cord in the restroom of a resident in one wing of the facility. Care staff arrived in 13 minutes and 39 seconds. After visiting the medication room, the LPA observed a resident in another wing of the building activate their pendant and care staff arrived in 1 minute and 3 seconds.

LPA concluded the inspection of the building by walking the perimeter with the DFA. There were no outbuildings or water features present. The exterior of the facility and the grounds surrounding it were in good repair at the present time.

According to California Code of Regulations, Title 22, the following deficiencies were observed during this inspection. They were cited on the LIC 809D page. Civil penalties were also assessed for the missing background check and lack of transfer associations.

A copy of this report was provided along with Appeal Rights.

Exit interview.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 6 of 17
Document Has Been Signed on 06/11/2024 05:35 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 06/11/2024 at 03:22 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 GOLD RIVER LODGE
FACILITY NUMBER: 347001241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the LPA observed a sharp 6 inch serrated knife in a memory care kitchenette cabinet and when she observed scissors in kitchenette drawer. These items posed/poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Designated Facility Administrator immediately removed prohibited items and has stated they will do daily checks of the common areas in memory care which will be logged. This log template will be submitted by 6/13/24 close of business and the logs themselves will be submitted to kimberly.viarella@dss.ca.gov by 6/20/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
Page: 7 of 17
Document Has Been Signed on 06/11/2024 05:35 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 06/11/2024 at 03:22 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 GOLD RIVER LODGE
FACILITY NUMBER: 347001241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and an interview with the Facility Administrator, the licensee did not comply with the section cited above as observed by they LPA during a review of staff files. In 2 of the 3 staff files, there was no proof of initial training documented. This posed a potential threat to the health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Designated Facility Administrator stated that he will provide an audit of all missing training for care staff and med techs and will also update Eskaton Academy materials to provide regulation references. This information will be submitted to kimberly.viarella@dss.ca.gov by 7/11/24.

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:Stephen Richardson
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
Page: 8 of 17
Document Has Been Signed on 06/11/2024 05:35 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 06/11/2024 at 03:22 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 GOLD RIVER LODGE
FACILITY NUMBER: 347001241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a records a review and an interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when 2 out of 3 staff files were missing required annual training components. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2024
Plan of Correction
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Designated Facility Administrator stated that he will provide an audit of all missing training for care staff and med techs and will also update Eskaton Academy materials to provide regulation references. This information will be submitted to kimberly.viarella@dss.ca.gov by 7/11/24.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a records review and interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when 2 out of 3 staff files reviewed staff did not have a current first aid/CPR certification. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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The Designated Facility Administrator stated he will have all care staff /medtechs First Aid/CPR certified by 07/11/24. Copies of certifications will be submitted to kimberly.viarella@dss.ca.gov.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


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Document Has Been Signed on 06/11/2024 05:35 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 06/11/2024 at 05:02 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 GOLD RIVER LODGE
FACILITY NUMBER: 347001241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
873559(e)

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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with the Designated Facility Administrator, the licensee did not comply with the section cited above when a minor hired to work as a server turned 18 last summer and the licensee did not obtain a background check clearance for them. This posed / poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Facility sent the staff member to be fingerprinted and they will not return to work until they have been cleared. THis POC has been cleared. As follow up, proof of clearance will be sent to kimberly.viarella@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
Page: 16 of 17
Document Has Been Signed on 06/11/2024 05:35 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 06/11/2024 at 05:05 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 GOLD RIVER LODGE
FACILITY NUMBER: 347001241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a record review and an interview with the Business Office Manager, the licensee did not comply with the section cited above when 4 employees transfered to this facility but requests for them to be associated were not completed. This posed / poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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These transfer requests have been completed. This POC has been cleared.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
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