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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 02/20/2026
Date Signed: 02/24/2026 09:18:13 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
10/29/2025 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20251029143101
FACILITY NAME:ESKATON GOLD RIVER LODGEFACILITY NUMBER:
347001241
ADMINISTRATOR:ALFREDO CRUZFACILITY TYPE:
740
ADDRESS:11390 COLOMA RDTELEPHONE:
(916) 852-7900
CITY:GOLD RIVERSTATE: CAZIP CODE:
95670
CAPACITY:134CENSUS: 86DATE:
02/20/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Alfredo CruzTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Due to lack of staff, staff are not answering residents calls for assistance timely
Unqualified staff giving injections to resident's
Staff do not safeguard resident records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Alfredo Cruz and explained the reason for the visit. Census: 86

Due to lack of staff, staff are not answering residents calls for assistance timely - LPA Lund reviewed facility records, interviewed, Staff, and Residents in care. Based on facility resident pendant calls from residents in care. 11/1/2025 through 11/30/2025 there were 2313 pendant calls with an average assistance time of 7 minutes and 55 seconds. Staff interviewed stated that they feel they have enough time to meet the needs of the resident’s care. Residents in care stated that their needs are being met.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
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 2
Control Number 27-AS-20251029143101
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: 02/20/2026
NARRATIVE
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Based on facility records, interviews with staff, and resident’s in care on the information provided, it was unclear if due to lack of staff, staff are not answering residents calls for assistance timely, therefore the allegation was deemed UNSUBSTANTIATED.

Unqualified staff giving injections to resident's - LPA Lund reviewed facility records and interviewed, Staff, and Resident’s in care. The facility hasn’t done injections for resident’s in care since approximately 2022. The facility has three residents who need injections and are able to do own injections based on needs and service plan. LPA Lund reviewed the Eskaton Diabetic Resident Guidelines for residents in care.

Based on facility records review interviews with staff and residents in care on the information provided, it was unclear if unqualified staff giving injections to resident's, therefore the allegation was deemed UNSUBSTANTIATED.

Staff do not safeguard resident records - LPA Lund interviewed Staff, and Administrator Alfredo Cruz. On 2/20/2026 LPA Lund observed in three different locations that resident’s records are secured with a locked door with a pin number to get into the records. Administrator Alfredo Cruz stated that only staff who need access to the residents’ records have the pin number to gain access to the records.

Based on interviews with Staff, Administrator Alfredo Cruz and LPA Lund’s observation on the information provided, it was unclear if staff do not safeguard resident records, therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2