Eskaton Village

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Resident Care Director, Chantel Krahn, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, two (2) bedrooms in memory care, two (2) shower rooms in memory care, and four (4) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the hot water temperature in one (1) room in assisted living, which was observed to be 106.1 degrees F. LPA checked the hot water temperature in one (1) room in memory care, which was observed to be 115.3 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and also reviewed six (6) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Mar 20, 2026

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: -Staff do not respond to resident's calls for assistance

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Resident Care Director, Chantel Krahn, to deliver complaint investigation findings regarding the above stated allegation. Interviews with residents (R1, R2, R3, R4, R5, and R6) indicated that staff respond to their calls for assistance. Interviews with residents indicated that staff respond to their calls for assistance quickly. According to R1's device activity report dated January 19, 2026-February 8, 2026, staff responded to all calls for assistance. Staff schedules for the months of January-February 2026 indicated that the facility is fully staffed for all shifts. Based on interviews conducted and documentation obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 20, 2026 · control 59-AS-20260206110346

Type of visit: Case Management - Other

Licensing Program Analyst, Angela Hood arrived on October 1, 2025 for an unannounced inspection to follow up on substantiated allegations of neglect resulting from a complaint investigation. On September 13, 2023, the Department concluded a complaint investigation, alleging the following: Facility staff did not adhere to resident’s special diet, and facility staff did not provide care and supervision during meals, resulting in the death of resident (R1). The licensee was cited for California Code of Regulations (CCR), Title 22, § 87555(b)(7) General Food Service Requirements, and CCR, Title 22, § 87464(f)(4) Basic Services. At the time of the complaint visit on September 13, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility not providing adequate care and supervision to R1. The facility did not adhere to R1’s physician’s diet order resulting in R1 choking, sustaining aspiration, cardiac arrest, hospitalization, anoxic cerebral injury, which resulted in R1’s death. Today, October 1, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on September 13, 2023, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Chantel Krahn name and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC421D.the state’s words, verbatim · CDSS document, Oct 1, 2025

Allegation investigated: -Staff do not treat resident with dignity and respect -Staff withhold food from resident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Healthcare Administrator, Sean Beloud, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Facility provided LPA their internal investigation, which did not indicate any findings of staff treating residents with a lack of dignity or respect, as well as staff withholding food from residents in care. Interviews with staff (S1, S2, S3, S4, and S5) indicated that they have never witnessed staff treating residents with a lack of dignity or respect. Residents (R1, R2, and R3) indicated that staff treat them well and are meeting all their needs. R2 and R3 indicated that staff are respectful. ***********************************************Continued on LIC9099-C*********************************************** Unsubstantiated Interviews with S1, S2, S3, S4, and S5 indicated that they have never witnessed staff withholding food from residents in care. R1, R2, and R3 stated that the food is good and that they get plenty of food to eat. R2 indicated that the facility weighs residents periodically. Facility provided LPA with the memory care unit's monthly weight records from March 2025-May 2025, which did not indicate any significant weight changes. S1, S2, S3, S4, and S5 indicated that they would report it if they witnessed staff treating residents with a lack of dignity or respect, as well as if they witnessed staff withholding food from residents. Staff also indicated that they are aware of the procedures for reporting incidents of suspected abuse. Based on interviews conducted and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 59-AS-20250502112328

Type of visit: Office

On June 5, 2025, a non-compliance conference was conducted. The purpose of this conference meeting was to address non-compliance at the facility after being issued 3 Type A citations and 3 Type B citations. Present in the meeting was CCLD staff, including Regional Manager Alycia Rayner, Licensing Program Manager Maribeth Senty, Licensing Program Analyst Angela Hood, and facility staff, including the Health Care Administrator Sean Beloud, Quality Improvement Executive Director Jennifer Marlette, and Chief Legal Officer Tom Garberson. The conference process was explained during this meeting. Issues discussed during this meeting were: · General Food Services regarding modified diets · Basic Services of residents · Administrator Qualifications · Reporting Requirements · Personnel Requirements The facility has stated that they will do the following to achieve continued and substantial compliance: · Conduct monthly audits for the next six (6) months beginning July 5, 2025-January 5, 2026 · Report any facility leadership changes, as well as their training, to CCL including dining managers, leads, and cooks · Ensuring timely reporting of incidents to CCL The facility has implemented policies and procedures to ensure substantial compliance. Facility was notified that the Department may increase monitoring at the facility and the completing of the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 3/19/25 and met with the Resident Care Coordinator, Chantel Krahn, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed six (6) bedrooms in assisted living, three (3) bedrooms in memory care, two (2) shower rooms in memory care, and four (4) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the hot water temperature in four (4) rooms in assisted living, which were observed to range between 110.8-114.7 degrees F. LPA checked the hot water temperature in two (2) rooms in memory care, which were observed to range between 114.1-116.2 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and also reviewed six (6) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Mar 19, 2025

Allegation investigated: -Facility staff are not changing bandage as ordered by home health

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/16/24, and met with the Resident Care Coordinator (RCC), Chantel Krahn, to open a complaint investigation and deliver findings regarding the above stated allegation. During today's visit, LPA reviewed documentation pertinent to the investigation and conducted interviews. Interviews with RCC and Home Health Nurse indicated that Resident (R1) is to receive wound care two times per week for a skin biopsy on the right foot. Home Health Nurse indicated that they typically only provide wound care for residents 2-3 times per week and anything more would need a signed physician's order. Home Health Nurse indicated that when the initial assessment was conducted with R1 it was agreed that they would be providing wound care two times per week. Home Health Nurse did not indicate ********************************************Continued on LIC9099-C*************************************************** Unfounded any concerns regarding the facility and stated that the facility's Wellness Nurse will provide wound care for R1 when requested by R1. R1's Progress Notes from 10/27/24-12/14/24 indicated that the facility nurses have provided wound care several times for R1 on the days that home health wound care is not scheduled. Home Health's Plan of Care indicated that they will be providing wound care one time per week starting 10/22/24 and two times per week beginning 11/3/24. Home Health Plan of Care also indicated that wound care will end effective 12/20/24. Based on interviews conducted and documentation reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with RCC and a copy of this report was provided to the facility. The signature of the RCC on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 59-AS-20241212093901

Allegation investigated: -Staff did not seek medical care in a timely manner for resident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 9/19/24, and met with the Resident Care Coordinator, Chantel Krahn, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. ***********************************************Continued on LIC9099-C*************************************************** Unsubstantiated Allegation: Staff did not seek medical care in a timely manner for resident. The concern was that staff (S1) did not contact hospice services for resident (R1). Interview with the Resident Care Coordinator (RCC) indicated that the day of concern was 5/17/24. RCC indicated that hospice services were contacted and hospice arrived the same day, 5/17/24, to provide care to R1. Interview with hospice services indicated that they were contacted by the facility on 5/17/24 and 5/19/24 to provide a hospice PRN visit. According to interview with hospice services and hospice documentation, R1 was seen on 5/17/24 for an occasional cough. Interview with hospice services indicated that R1 denied any pain and there was no notation of R1 having anxiety during the visit. On 5/17/24, hospice nurse provided a nebulizer treatment for R1. Interview with hospice services indicated that the facility contacted them frequently and that they had no concerns regarding the facility. Interviews with staff (S1, S3, and S4) indicated that they have never observed staff not providing timely care to residents. Interviews with S1, S3, and S4 indicated that staff contact hospice services immediately when a hospice resident requires medical attention. Interview with resident (R2) indicated that they receive timely medical attention from facility care staff. Interview with resident (R3) indicated that they have not had any medical emergencies. Interviews with R2 and R3 indicated that they make all of their medical appointments. Based on interviews conducted and documentation obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 59-AS-20240524160147

Allegation investigated: Staff are not providing resident with incontinence care. Staff did not respond to resident’s call button.

On 4/16/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Chantel Krahn, Resident Care Coordinator, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. LPA Mknelly reviewed the Observation Detail List (ODL) assessment of needed services for residents who reside in Hall 1 of assisted living (rooms 16-40), as well as the call system Device Activity Report (DAR) for assisted living for the dates of 2/11/24- 2/18/24. For the ODL’s provided for review on 2/29/24, 3 residents are identified as needing Level 4 assistance, 8 residents require Level 3 assistance, 3 require Level 2 assistance and 2 residents do not require more than basic services. Report continued. Substantiated The facility’s Admission Agreement template from 2010 in the facility file in the Sacramento CCLD office, identifies: Level Four- Extensive Assistance. Resident requires extensive assistance for personal care, bowel and bladder management, and health care monitoring. Behavior may be unpredictable and continual orientation and cueing may be needed for all basic functioning. Housekeeping and laundry needs may be more than daily. All services in Levels One, Two and Three would be required; Level Three- Moderate assistance. Resident's needs are more intense and include moderate assistance in activities of daily living as well as constant supervision and moderate assistance for dressing and bathing. Medication administration assistance may be more complex, and health monitoring may be as often as daily (e.g., blood pressure checks). Physical assistance in preparation for and during transports outside the facility may be necessary. Physical assistance and escort to the dining room and constant cueing and assistance during mealtimes would most likely be needed. Tray services may be used frequently. Laundry and housekeeping services may be required daily. Resident may require regular assistance in bowel and bladder management. All services included in Levels One and Two would be required; and Level Two- Minimal Assistance. The DAR provided to the investigating LPA contained approximately 835 pendant calls for the week or 2/11/24-2/18/24 in Assisted Living. Of the 835 calls, LPA found that approximately 177 responses exceeded 20 minutes. Given the content of the complaint allegation, LPA then reviewed information for 2/15/24, Hall 1, and found that there were 16 call responses exceeding 19 minutes and 50 seconds. 10 of the incidents, in Hall 1 on 2/15/24, occurred on the AM shift and 6 on the PM shift. Of the residents impacted by call response delays, 4 were designated as Level Three and 1 was Level Four. Resident records indicate that the longest recorded response times, in Hall 1, on 2/15/24 were experienced by R1, who is Level 4, who had a wait time of 63:05 (min:sec) and R5, who is Level 3, had a wait time of 67:42 (min:sec). R1’s delay occurred at 10:48 AM and interviews conducted found that the delay resulted in a delay in incontinence care for R1. When interviewed by LPA, R5 was unable to recall the reason for their call on 2/15/24. However, R5’s ODL identifies R5 as using a catheter, needing stand-by assist for toileting, is a fall risk and requires frequent check. CCR 87411 Personnel Requirements – General states, in part, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” LPA interviewed seven (7) residents who had recorded incidents of long (greater that 19 min 50 sec) response times. Seven of seven residents interviewed stated that while many response times are less than 15 minutes, they all have experienced response times more than 20 minutes. All seven have had staff explain delays to them as staff were providing service to another resident as the reason for the delay. All residents interviewed stated they experience routinely longer wait times around meals and bedtimes, where more residents need assistance at the same time. LPA interviewed seven (7) caregivers. All seven stated that they have been working when call times have exceeded what they all have understood as company direction to not exceed 15 minutes. On 2/15/24, when R1 was incontinent and waiting for assistance, interviews and records found that S1 was assigned to hall one. When R1 called for assist at 10:48, S1 was assisting another resident, R2, with bathing. Staff interviews did not provide specific reason why the 2 medication technicians (MT) or the other caregiver working (S2) in hall 2 did not respond timely on 2/15/24. All staff interviewed stated that reasons for delays in response times include but are not limited to insufficient staff (staff call offs), staff engaged with other residents/ duties and pager or pendant malfunctions. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 16, 2024 · control 59-AS-20240215152024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: May 15, 2024

Managed Incontinence- (b)… the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met based on records and statements that on 2/15/24, R1 was not assisted with incontinence for an extended period. This posed a potential risk to the resident.the state’s words, verbatim · CDSS document, Apr 16, 2024

Plan of correction: Licensee will submit a detailed plan of care for R1 that meets the requirements of this regulation, by the POC date of 5/15/24. This plan of correction is to be applied to all residents with incontinence. Plans to be maintained on file.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 15, 2024

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on documents and statements that showed at times there are insufficient staff to meet the needs of residents. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2024

Plan of correction: Licensee for resident call response times. The plan will address the following factors: pendants and Pagers are well maintained; a system of Communication between facility staff when unable to respond; ID of residents known to have potential urgent needs (incont., heart issues, impulsive if delayed response , etc); A minimum general response time; Auditing of long call times; Notes for call time length errors; a system for determining staffing, in real time, based on identified needs; and whether non-care duties such as laundry require additional staff for that task.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 3/27/24 and met with the Resident Care Coordinator, Chantel Krahn, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, two (2) bedrooms in memory care, two (2) shower rooms in memory care, and four (4) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 105.1 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files and also reviewed two (2) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Mar 27, 2024

Allegation investigated: Facility fire alarm is in disrepair.

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Monday March 4, 2024, to complete and deliver findings for a complaint received on 1/10/2024. LPA met with Administrator Greg and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and Campus Patrol. LPA reviewed fire watch logs and emails between the facility and the Fire Department. The result of the investigation is as follows: LPA learned that between 1/9/2024 and 1/10/2024, there were two false fire alarms that occurred at the facility. The facility learned that one fire detector was defective and immediately replaced the device. A few hours later, the facility learned that the replacement device was defective and replace it. Therefore, there were two false alarms. The facility immediately initiated fire watch (for approximately 20 hours) and supplied the logs to the Fire Department. Separately, the facility has a long-term project, which has been Unsubstantiated approved by SacMetro, to replace the fire panels, however, this does not impact the system from being fully functional. This project is set to be complete in April 2024. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNSUBSTANTIATED. a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview conducted. A copy of this report was left with the facility.the state’s words, verbatim · CDSS document, Mar 4, 2024 · control 59-AS-20240110121302