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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 08/20/2025
Date Signed: 08/20/2025 05:10:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
11/24/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20241124082003
FACILITY NAME:ESKATON GOLD RIVER LODGEFACILITY NUMBER:
347001241
ADMINISTRATOR:TINA RILEYFACILITY TYPE:
740
ADDRESS:11390 COLOMA RDTELEPHONE:
(916) 852-7900
CITY:GOLD RIVERSTATE: CAZIP CODE:
95670
CAPACITY:134CENSUS: 85DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Alfredo Cruz TIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Due to staff neglect, resident developed sepsis resulting in hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Viarella, arrived at the facility unannounced to deliver the findings of this complaint investigation. LPA met with Administrator / Executive Director (ED) Alfredo Cruz and explained the reason for the visit.

The initial 10-day visit was completed on 11/24/24, where the LPA reviewed and obtained copies of resident records including but not limited to physician’s report, admission agreement and daily on-going notes. In addition to the records already noted, the Department obtained medical records from the acute hospital, interviewed staff and witnesses.

It was alleged that “due to staff neglect, resident 1 (R1) developed sepsis resulting in hospitalization.” EMS was called on 11/06/2024 to assess R1 due to R1 not feeling well, weakness and confusion. R1 refused to go the ER. The following day R1 was again not feeling well with weakness and confusion. R1 was then taken to the local hospital. On 11/07/2024, Resident 1 was admitted to the hospital for “weakness”. R1
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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 5
Control Number 27-AS-20241124082003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2025
NARRATIVE
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presented in the emergency room (ER) with an “altered mental status, fatigue and generalized weakness…” R1 was diagnosed with sepsis. Interviews with staff noted that R1 would refuse treatment. Facility documentation notes that staff checked on R1 when they observed a change in condition. It was unclear if R1 developing sepsis was due to staff not obtaining timely medical attention or due to R1’s refusal for treatment. Due to these inconsistencies, there was not a preponderance of evidence to substantiate that hospitalization was a result of lack of care and supervision. The allegation was UNSUBSTANTIATED and no deficiencies were cited.

Exit interview was conducted with Executive Director and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
11/24/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20241124082003

FACILITY NAME:ESKATON GOLD RIVER LODGEFACILITY NUMBER:
347001241
ADMINISTRATOR:TINA RILEYFACILITY TYPE:
740
ADDRESS:11390 COLOMA RDTELEPHONE:
(916) 852-7900
CITY:GOLD RIVERSTATE: CAZIP CODE:
95670
CAPACITY:134CENSUS: 85DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Alfredo Cruz TIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Facility did not properly assess resident in care.
Facility did not allow resident to come back to the facility after being hospitalized.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Viarella arrived at the facility unannounced to deliver the findings of this investigation. LPA met with Administrator (AD) Alfredo Cruz and explained the reason for the visit. The initial 10-day visit was completed on 11/24/24, where the LPA reviewed and obtained copies of resident records including but not limited to physician’s report, admission agreement and daily on-going notes. In addition to the records already noted, the Department obtained medical records from the acute hospital, interviewed staff and witnesses.

It was alleged that “Facility did not properly assess resident in care.” Per facility documentation dated 11/05/2024 at 5:36 PM, staff observed Resident 1 (R1) to have a change in condition. Staff noted R1 to have difficulty transferring requiring full assistance. Staff took R1’s vitals recording R1’s temperature to be 99.4 degrees Fahrenheit (F). R1 was checked about four hours later and their temperature at this time was 95.7 degrees F. The following day on 11/06/24 at 11:02 AM, facility notes state R1 was not feeling
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241124082003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2025
NARRATIVE
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well, experiencing weakness, confusion and runny nose. On 11/06/2024, at 6:30 PM, R1 was seen by paramedic due to weakness and back pain. R1 refused to go to the ER. On 11/07/2024 at 12:29 PM the home health agency providing services to R1 called 911 due to R1’s weakness and confusion. Staff became aware of R1 having a change in condition on 11/5/2024. Staff interviews and facility notes do
not show that staff contacted R1’s primary care provider (PCP) when the change of condition was noted.  Based on documentation and information provided through interviews there was a preponderance of evidence to show that the facility did not properly assess resident and did not report the change in condition to PCP as required and therefore this allegation is SUBSTANTIATED.

It was alleged that “Facility did not allow resident to come back to the facility after being hospitalized.”  Per facility documentation dated 11/18/2024 at 3:18PM, the facility was notified that R1 would be discharged back to Eskaton Gold River the following day on 11/19/2024.  On 11/19/2024, the Resident Care Coordinator (RCC) for the facility called the hospital requesting that R1 be transferred to a skilled nursing facility for rehabilitation, stating that R1 has to be able to bare weight otherwise R1 is not appropriate for the facility.  The facility should have allowed R1 to return home as the hospital stated that R1 needed a 2-person assist, and not any mechanical interventions/accommodations.  The facility refused.  The facility should have allowed R1 to return home, re-assessed R1's needs, and updated R1's care plan.

If after a thorough assessment, it was determined that the facility could not continue to meet R1's needs, the responsible party should have been notified.  An updated care plan should have been created and a draft of a 30-day eviction letter stating that the resident required a higher level of care, along with supporting documentation, should have been submitted to Community Care Licensing for review.  The facility should have also assisted the resident and their responsible party in locating an appropriate placement, as required.
Based on documentation and information provided through interviews there was a preponderance of evidence to show that the "Facility did not allow resident to come back to the facility after being hospitalized," and therefore this allegation is SUBSTANTIATED.

Exit interview was conducted with AD Alfredo Cruz and a copy of this report was provided along with APPEAL RIGHTS.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20241124082003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2025
Section Cited
CCR
87466
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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional... appropriate assistance is provided...
The Licensee did not meet the above requirement when:
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The Licensee hired a new Executive Director as of 12/05/24 and the new ED has held the team accountable with regard to reporting requirements and residents' change of condition. There is also a new Resident Care Director to oversee assessments, re-appraisals and family care conferences
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Based on a review of records and interviews, staff became aware of R1 having a change in condition on 11/5/2024 and staff did not contact R1’s (PCP) when the change of condition was noted. This posed an immediate threat to the health, safety and personal rights of residents in care.
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This POC has been cleared.
Type A
08/21/2025
Section Cited
CCR
87468.2(a)20
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 Additional Personal Rights of Residents in Privately Operated Facilities
(20) To be protected from involuntary transfers, discharges, and evictions...
The Licensee did not meet the above requirement when:
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The ED will communicate with residents and responsible parties Eskaton's policy regarding resident transfers and the use of mechanical lists. This will be accomplished though a recorded Family Meeting on 08/21/25. The agenda and link to the meeting will be forwarded to
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Based on a review of records and interviews, on 11/19/24, the RCC did not allow R1 to return to the facility when the hospital tried to discharge R1 so R1 could return home. This posed an immediate risk to the health, safety, and personal rights of residents in care.
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CCLASCPSacramentoRO@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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5