347001241-3-5-2026-27-AS-LKIG-DS9KRH-20260317080759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001241
Report Date: 03/05/2026
Date Signed: 03/05/2026 03:19:53 PM

Substantiated

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
12/09/2025 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20251209104008

FACILITY NAME:	ESKATON GOLD RIVER LODGE		FACILITY NUMBER:	347001241
ADMINISTRATOR:	ALFREDO CRUZ		FACILITY TYPE:	740
ADDRESS:	11390 COLOMA RD		TELEPHONE:	(916) 852-7900
CITY:	GOLD RIVER	STATE: CA	ZIP CODE:	95670
CAPACITY:	134	CENSUS: 89	DATE:	03/05/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Alfredo Cruz		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not accord resident with dignity

INVESTIGATION FINDINGS:

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On 3-5-2026 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegation noted above. LPA met with Administrator Alfredo Cruz and explained the purpose of the visit.
Allegation: Staff did not accord resident with dignity. During this investigation, LPA conducted interviews with seven staff members and four residents in care. LPA also conducted facility observations and reviewed staff record for staff8 (S8). Based on interviews and record reviews, it was revealed that in December 2025, S8 engaged in conduct toward a resident resulting in a lack of privacy and dignity for the resident which included checking a resident for toileting needs in the hallway common area of facility. A review of employee records states that S8 was counseled by facility management regarding this incident which states “RCA did not provide privacy and dignity for the resident.” As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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 4

Control Number 27-AS-20251209104008

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: 03/05/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/16/2026 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee will ensure completed staff training on resident rights. Training to include but not be limited to Section 87468.1(a)(3). Proof of completed training to be submitted to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, Licensee did not ensure a dignified relation between a staff member and resident in care regarding care procedures. This posed a potential health, safety, and resident rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
12/09/2025 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20251209104008

FACILITY NAME:	ESKATON GOLD RIVER LODGE		FACILITY NUMBER:	347001241
ADMINISTRATOR:	ALFREDO CRUZ		FACILITY TYPE:	740
ADDRESS:	11390 COLOMA RD		TELEPHONE:	(916) 852-7900
CITY:	GOLD RIVER	STATE: CA	ZIP CODE:	95670
CAPACITY:	134	CENSUS: 89	DATE:	03/05/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Alfredo Cruz		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff handled resident in a rough manner
Staff not providing food to residents in memory care when requested
Staff not responding to memory care resident needs as required

INVESTIGATION FINDINGS:

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On 3-5-2026 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegations noted above. LPA met with Administrator Alfredo Cruz and explained the purpose of the visit. During this investigation, LPA conducted interviews with seven staff members and four residents in care. Additionally, LPA reviewed facility file documentation and conducted facility observations including meal service observations.

Allegation: Staff handled resident in a rough manner. This allegation specifically alleged that a memory care resident was handled in a rough manner during a care procedure. LPA conducted interviews, record reviews, and observations as noted above. Based on these interviews, record reviews, and observations it was revealed that no corroborated statements or evidence existed to prove residents have been handled in a rough manner. Additionally, interviews and observations did not reveal any direct witnessing of rough handling. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. {Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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 4

Control Number 27-AS-20251209104008

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: 03/05/2026

NARRATIVE

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Allegation: Staff not providing food to residents in memory care when requested. LPA conducted interviews, record reviews, and observations as noted above. Based on observations and record reviews, it was revealed that residents in memory care received food items during mealtimes as well as through special requests of residents. LPA observed various residents in memory care served timely and in accordance with diet orders. Additionally, interviews conducted did not reveal any corroborated statements or evidence supporting the allegation noted above. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

Allegation: Staff not responding to memory care resident needs as required. LPA conducted interviews, record reviews, and observations as noted above. LPA observed residents in memory care attended to timely including toileting needs, redirection as necessary, and general supervision of residents. Additional observations in memory care revealed timely assisting of residents in under ten minutes. Interviews conducted revealed that staff are attending to resident needs timely and adequately, with no further corroborated evidence to support the allegation noted above. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC9099 (FAS) - (06/04)

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