Eskaton Gold River Lodge

On 09/17/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. The LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). The LPA met with Executive Director, Neal Torres and a brief interview followed. Regarding: Staff did not follow protocols to prevent the spread of illness. On 02/23/24, 4 residents were temporarily relocated to Eskaton Gold River Lodge from Eskaton Village in Carmicheal due to a flood in the memory care community in Carmicheal. This LPA learned through interviews that one of the resident's at the Carmicheal facility tested positive for COVID prior to being transferred to a third Eskaton facility in another city. This LPA also learned through interviews that all of the other residents being relocated tested negative for COVID prior to transfer. SubstantiatedRead the full finding— CDSS inspection report, September 17, 2024 · control 27-AS-20240229151350

On 07/17/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings to this investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with DFA / Executive Director Neal Torres and a brief interview followed. LPA and DFA conducted a walkthrough of the facility with particular time and attention spent on the kitchen. LPA observed 7 staff in the kitchen. LPA did not observe anyone with long, loose, unsecured hair. The kitchen was clean, organized, condiment station was clean, all lids were secured, individual bulk items like packaged cookies were in dated bins. There had been a new delivery of frozen foods and items were boxed and shelved accordingly. LPA observed 4 residents in the dining room finishing up breakfast and 2 servers on hand to assist them. With regard to the allegation, "Staff are not providing adequate food servRead the full finding— CDSS inspection report, July 17, 2024 · control 27-AS-20240320134223

On 6/24/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open a complaint investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the designated facility administrator (DFA). LPA met with Neal Torres. A brief interview followed and the LPA requested the following documents: LIC 500 with contact information, Resident Roster, care and med tech staff schedules for the day in order to conduct interviews. LPA observed the following during her visit: 9 residents participating in card games in the activity room. 40 residents seated and ready for dinner in the dining room. Medications being distributed in Memory Care. Through interviews, this LPA learned that Assisted Living had 4 - 5 care staff (and sometimes a floater) for the AM shift with 2 med techs along with a nurse and the Resident Care Coordinator or his Assistant. The PM shift typically had 4 care staff, 2Read the full finding— CDSS inspection report, June 24, 2024 · control 27-AS-20240620111402

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Neal Torres and explained the purpose of the visit. This investigation consisted of interviews and record review. During the course of this investigation, LPA Moleski interviewed Torres, three residents (R1-R3), seven medication technicians (S2-S8), and one licensed nurse (S1). According to Torres, four residents were taking injectable insulin (R1-R4) at the onset of this investigation. R4 has been out of this facility and is currently at a skilled nursing facility. LPA Moleski reviewed four months' worth of medication administration records for R1-R4’s injectable medications. LPA Moleski compared employee initials in these records to a list of employees and observed that initials for these injectable medications corresponded with the initials of licensed nurses, or with medication technicians. [continued on 9099-C] UnsubstantiateRead the full finding— CDSS inspection report, April 18, 2024 · control 27-AS-20240216084025

This report is being amended to revise the findings delivered on 11/16/23 as the department has obtained additional information regarding the allegations. Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Eskaton Gold River Lodge (RCFE) on 2/7/24 at 9:15 am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Neal Torres and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. Based on the department’s investigation, on 6/25/23 the deceased resident exited the facility front doors after an unknown guest had unlocked the front doors to exit the facility. When staff arrived to ensure guests exited appropriately, staff observed guests had already left, the staff member looked around the front porch of the facility and then locked the doors with resident outside the facility. Report Continued on LIC 9099-CRead the full finding— CDSS inspection report, February 7, 2024 · control 27-AS-20230705114802

This report is being amended to revise the findings delivered on 11/16/23 as the department has obtained additional information regarding the allegations. Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Eskaton Gold River Lodge (RCFE) on 11/16/23 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Neal Torres and together discussed the investigation details. The department could not corroborate the allegations regarding the cleanliness of R1's bathroom. LPA Gould made an unannounced inspection on 7/6/23 and conducted a tour of the facility to ensure health and safety of residents and observed the resident's bedroom and bathroom to be clean and well maintained. Interviews with housekeepers at the facility did not reveal any pattern or documentation of the bathroom being dirty. The department could not obtain any evidence to support the facility not being clean, sanitary and in an odorless condition.Read the full finding— CDSS inspection report, November 16, 2023 · control 27-AS-20230705114802

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Eskaton Gold River Lodge (RCFE) on 8/16/23 at 9:30am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. LPA conducted interviews with six staff members and three residents including the alleged victim. All staff interviewed denied the allegations and provided statements that resident frequently is unable to locate an item in her room due in part to poor vision. All staff interviewed indicated that the item identified as missing is always recovered in the room. it is usually related to items of clothing including bras and scarves. Two of the three residents interviewed denied items going missing from room. Report continued on LIC 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, August 16, 2023 · control 27-AS-20230503081017

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Eskaton Gold River Lodge (RCFE) on 1/4/23 at 9:15am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because LPA was unable to corroborate any of the above allegations. LPA attempted to interview the alleged victim on several occasions and each time the resident refused to be interviewed by LPA. Additionally, LPA observed resident to be clean and in clean clothing each time resident was observed by LPA. Staff interviewed each identified specific bathing dates and could not be corroborated by resident as she refused interviews. LPA reviewed resident's clothing inventory and LPA observed a limited suppy of tops which may account for resident being observed in the same clothing.Read the full finding— CDSS inspection report, January 4, 2023 · control 27-AS-20221107143758

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Eskaton Gold River Lodge RCFE on 12/22/22 at 1:30pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because reporting party denied any concerns regarding staff behavior posing a risk to residents in care. Additionally, upon further investigation, the alleged perpetrator is not a staff member at the facility and is a private companion and is not responsible for any care and supervision. LPA interviews revealed that the resident companion had been spoken to regarding her interactions with staff in the past and there have been no further reports or issues reported to the administrator since. Report Continued on LIC 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, December 22, 2022 · control 27-AS-20221114133215

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Eskaton Gold River Lodge (RCFE) on 12/20/22 at 1:30pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because LPA could not corroborate the allegations. LPA reviewed resident's file and conducted interview. LPA also conducted interviews with appropriate staff members including administrator and head of nursing. LPA determined that resident did in fact make statement of self harm whereby the facility staff, upon being notified of self harm statements by resident initiated the facility plan for 1 on 1 supervision for resident until the resident could be re-evaluated by a physician and cleared to return to regular supervision. LPA and the department have determined that the enhanceRead the full finding— CDSS inspection report, December 20, 2022 · control 27-AS-20220914143505

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Eskaton Gold River Lodge (RCFE) on 10/21/22 at 1:50pm to conclude the investigation of the above allegation and to deliver the findings. LPA met with Staff Karen Peets and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated because Resident #1 was confirmed to have received an additional dose of once-weekly medications administered the day following their scheduled dose. Staff interviewed and incident reports received from the facility confirmed the allegation. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medication is substantiated but if any additional information is received this complaint can be amended and the finding can be changed. SubstantiatedRead the full finding— CDSS inspection report, October 21, 2022 · control 27-AS-20220802145540

This is an amended report to correct LPA error of unfounded complaint findings regarding the allegation: Resident was attacked by another resident resulting in serious injury. Although R1 did not sustain any injuries as a result of an aggressive act by R2, LPA incorrectly determined the entire allegation was unfounded which misrepresents LPA's investigation which clearly finds that R1 was assaulted by R2. Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Eskaton Gold River Lodge (RCFE) on 2/24/22 at 9:45am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details. The allegation that R1 did not receive timely or adequate medical attention cannot be corroborated. LPA conducted interviews with S1 and A1 who both confirmed R1 went to the hospital on the day of the reported incident and was met at the hospital by family who advocated for additional testing incluRead the full finding— CDSS inspection report, February 24, 2022 · control 27-AS-20211025152643