Eskaton Village Roseville

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with David Dingcong during today's inspection. The department received an incident report from the facility concerning R1. R1 is a memory care resident and was found by the campus patrol near the homes on the property. All memory care rooms have a window and the window has a lock in which only allows window to be opened about 2 inches. R1 had broken the window lock and left the facility through the window. R1 had no injuries and was moved to a room where the window faces into the memory care outdoor area that is secured. Hospice and family were notified. It is determined facility is acting appropriately and staff are following up with the appropriate parties. At the time of this visit no deficiencies were given. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Stephen MacDonald during today's inspection. LPA received an incident report that on 4/9/26, it was discovered that a medication error occurred for R1 for several days. Staff gave R1 a double dose of Lovastatin for 5 doses and R1 missed their Levothyroxine for 5 doses. Physician and family were informed of medication error. Training for staff has been given. Deficiencies cited on 809-D. Appeal rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 24, 2026

87465(a)(4) Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medications as needed. This requirements was not met by evidenced by: Medication was given incorrectly to resident in care. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 17, 2026

Plan of correction: Administrator has completed training with staff regarding medication errors. Administrator agrees to send into LPA a copy of training given to staff and a statement of the actions that took place to resolve the errors that occurred. POC due by 4/20/26.

Allegation investigated: Staff neglect led to resident's injury Staff did not provide a safe environment for residents in care

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Administrator Stephen MacDonald during today’s inspection. LPA investigated allegation, “Staff neglect led to resident's injury”. LPA interviewed relevant parties, residents, and staff and reviewed resident documentation. Relevant party (RP) stated R1 was admitted into the facility and staff were aware that R1 was a smoker and R1 was told they could smoke in the gazebo near the front entrance. Few days into their stay at the facility, R1 was told they would need to move to the smoking area at the back of the building. There was a back exit near R1’s apartment, however RP stated the door was too heavy for R1 to use. In December 2025, R1 attempted to exit the building on their own and hurt their back. R1 was seen in the hospital and was diagnosed with a compression fracture of the spine. Relevant party stated that staff should not have provided a smoking area that was not safe for R1 to access. Continuation on 9099-C. Unsubstantiated LPA interviewed administrator in which they stated they did not inform R1 that they could smoke in the gazebo area as it is against state law to smoke that close to the building entrance. Administrator stated that they did provide an alternative area for resident to smoke safely at. Administrator stated residents were not receiving any care at the time of the incident. LPA reviewed resident’s documentation which shows resident has a history of osteoporosis and other health related diagnosis. LPA reviewed hospital documentation from the visit following the incident in which it states resident was diagnosed with a spinal fracture. Due to the information gathered, LPA is unable to determine if staff neglect led to residents injury. Allegation is found to be UNSUBSTANTIATED. LPA investigated allegation, “Staff did not provide a safe environment for residents in care”. LPA interviewed relevant parties, residents, and staff and reviewed resident documentation. Relevant party stated R1 is a smoker and was told they would need to move to the smoking area at the back of the building. Relevant party stated in order to get to the smoking area from the back exit, R1 had to either step down from the curb onto the parking lot or use a ramp which had obstructions and tripping hazards. Relevant party showed LPA photos of a hose near the ramp and other boxes which could cause a tripping hazard. The smoking area was eventually moved to a different location in the front of the building that had coverage and more accessible for R1. LPA toured the facility and observed where the past smoking area was located and LPA did not see any obstruction or tripping hazards present. LPA reviewed R1’s documentation in which it states resident is non-ambulatory due to the use of a walker and has macular degeneration. Due to the information gathered, LPA was unable to determine if staff did not provide a safe environment for residents in care. Allegation is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 59-AS-20260116142539

Allegation investigated: Staff do not provide adequate quantity/quality of food to residents in care.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open complaint investigation. LPA met with Administrator Stephen MacDonald during today's investigation. During today's investigation, LPA interviewed staff and residents and toured the facility and kitchen. LPA interviewed administrator in which he stated the facility has weekly menus for the specials for breakfast, lunch, and dinner. In addition, they have a menu that is consistently available for residents to choose from. LPA toured the kitchen which including the refrigerator, freezer, and dry storage. LPA observed sufficient amount of food to meet the 2-day perishable and 7-day non-perishable amount of food. LPA interviewed 3 residents, of which 3 of 3 residents stated there is sufficient amount of food, and a variety of fresh foods are always available. Due to the information gathered, LPA finds allegation to be UNFOUNDED. Exit interview conducted and copy of report provided. Unfoundedthe state’s words, verbatim · CDSS document, Feb 11, 2026 · control 59-AS-20260205121821

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete the annual inspection. LPA met with Administrator Stephen MacDonald during today's inspection. Currently there are 12 residents receiving hospice care. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 7 resident rooms, medication rooms, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 15 resident files and 14 staff files. LPA reviewed 4 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed and CPR and first aid certificates present. LPA observed a copy of current liability insurance. No deficiencies cited during today's inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 23, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met Administrator Stephen MacDonald and David David Dingcong during today's inspection. LPA reviewed 15 resident files. LPA observed all required paperwork was present in resident files. At this time LPA will return on a later date to continue and complete annual inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Amandeep Gill during today's inspection. During today's inspection LPA interviewed staff and reviewed R1's documentation and hospital discharge paperwork. It is determined facility is acting appropriately and staff are following up with the appropriate parties. At the time of this visit no deficiencies were given. Exit interview and report provided.the state’s words, verbatim · CDSS document, Nov 12, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived announced at the facility to follow up regarding a death report for a non-hospice death. LPA reviewed documents pertinent to Resident R1. LPA spoke with Executive Director and Resident Care Director regarding report. Facility investigated and did not find any suspicious circumstances. At this time, no deficiencies are being cited. Exit interview conducted with Executive Director. Copy of report given to facility.the state’s words, verbatim · CDSS document, Jun 17, 2025

Allegation investigated: Staff do not ensure that residents' rooms are clean and sanitized. Resident's rooms are malodorous.

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with David Dingcong to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiated Staff do not ensure that residents' rooms are clean and sanitized. Licensing Program Analyst (LPA) Cassandra Mikkelson toured the facility during the investigation. LPA reviewed documents pertinent to the investigation which indicated that resident’s rooms are being cleaned and maintained by staff. LPA reviewed work orders placed at the facility for maintenance like carpet and floor cleanings which indicated staff and maintenance teams were cleaning on a regular basis to keep the facility and resident rooms clean and sanitized. The allegation that staff do not ensure that resident rooms are clean and sanitized is unsubstantiated. Resident's rooms are malodorous. Licensing Program Analyst (LPA) Cassandra Mikkelson toured facility during investigation. LPA observed no odors in common areas and hallways. LPA toured multiple residents and observed no odors. Interviews with residents indicated that staff regularly assist with cleaning and help keep each resident’s room clean and free of odors. The allegation resident’s rooms are malodorous is unsubstantiated. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is 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 was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Resident's toileting needs are not being met Licensing Program Analyst (LPA) Cassandra Mikkelson toured the facility during the investigation. Interviews with Resident R1, R2, R3, and R4 indicated that they were satisfied with the care they were receiving at the facility. LPA toured four (4) resident rooms which indicated clean and sanitary environments for each resident in care. Records reviewed indicated that each resident was receiving the assistance that was listed in their needs and services plans. The allegation that resident’s toileting needs are not being met is unfounded. Resident's hygiene needs are not being met Licensing Program Analyst (LPA) Cassandra Mikkelson toured the facility during the investigation. Interviews conducted with residents indicated that resident’s hygiene needs are being met and there are no complaints regarding hygiene care. Records reviewed indicated that residents are receiving assistance with hygiene needs according to their care plans. LPA toured four (4) resident rooms and observed resident rooms and bathrooms were clean with no odors. The allegation that resident’s hygiene needs are not being met is unfounded. Facility has mold Licensing Program Analyst (LPA) Cassandra Mikkelson toured the facility during the investigation. LPA toured the kitchen area where mold was alleged. LPA observed kitchen to be clean and free of visible mold. Records reviewed indicated that staff clean multiple times daily and monitor kitchen area for any potential mold hazards. Interviews conducted indicated that kitchen staff monitor for any hazards and report to management. No mold has been observed currently by staff. The allegation that facility has mold is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 28, 2025 · control 59-AS-20250515095816

Type of visit: Case Management - Incident

Licensed Program Analysts (LPAs) Cassandra Mikkelson and Cheyenne Ratajczak arrived at the facility and met with Business Services Manager Kay DeVault for a case management visit. LPAs followed up regarding a LIC624 sent to CCLD regarding resident R2's blood sugar levels. LPAs reviewed medication records, blood sugar logs and R2's physician's report. LPAs reviewed records which indicated facility followed proper protocols regarding incident. LPAs followed up regarding incident involving Resident #1 (R1) was being financially abused by the nail salon services for about a year. LPAs reviewed termination letter given to vendor dated February 11, 2025. LPAs also reviewed new policies and new consent form with Kay DeVault and Executive Director Alicia Rist, on the phone, that has been put into place. At this time, deficiencies are not being cited. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Feb 26, 2025

Type of visit: Case Management - Incident

On 02/04/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit. LPA met with Business Office Manager Kay DeVault and explained the purpose of the visit. The purpose of the visit is to gather additional information regarding an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 01/27/2025. The report indicates that Resident #1 (R1) was being financially abused by the nail salon services for about a year. During LPA interview with the Business Office Manager it was revealed that the facility did file a police report. Interview further revealed that when it comes to the nail salon services the facility has an outside vendor that comes in about twice a week to provide services to residents. These services are only provided if the resident is signed up for them. At this time the facility has suspended those services with the vendor. Additionally, LPA gathered pertinent documents relevant to the incident. At this time, deficiencies are not being cited. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Required - 1 Year

On 01/23/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced to conduct the annual inspection. LPA met with Interim Executive Director (IED) Alicia Rist and explained the purpose of the visit. Currently there are 90 residents of which 17 residents are receiving hospice care. LPA toured facility with IED to ensure health and safety of residents in care. LPA toured ten (10) resident rooms, medication room, bathrooms, kitchen, common living spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for two (2) day perishable and seven (7) day nonperishable. LPA reviewed drill logs, which are current. LPA reviewed ten (10) resident files and ten (10) staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA reviewed four (4) resident medications comparing with current physician orders. LPA requested facility to send a copy of the current liability insurance. LPA completed the full care tool and no deficiencies was observed. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Jan 23, 2025

Type of visit: Case Management - Incident

On 1/17/2025, Licensed Program Analyst (LPA) Cassandra Mikkelson and Licensed Program Manager (LPM) Laura Munoz arrived at the facility to conduct a case management visit regarding two (2) LIC 624 reports sent to CCL. The facility sent the department an LIC 624 on 01/07/2025 which stated that R1 was sent to the hospital on 12/30/2024 for shortness of breath. Family contacted the facility on 01/06/2025 to report R1 passed away due to pneumonia. A review of R1's LIC602/physician's report indicated R1 had a diagnosis of COPD and respiratory failure. R1's needs and service plan and physician orders indicated R1 was on oxygen at bedtime. Staff indicated R1 would be seen walking around the facility with their oxygen regularly. Based on the documentation reviewed and interviews conducted, no further follow up is needed at this time. The facility sent the department an LIC 624 on 01/03/2025 which stated that resident R2 was given the wrong dose of Omeprazole. LPA and LPM spoke with Tricia Diaz, LVN RCC, she stated that R2 was originally taking medication two times daily but their physician changed the order to one time daily in October 2024. Per Ms. Diaz facility received order but did not update in their Medication Administration Records (MAR). Medication error was found while attempting to refill medication in December 2024. Facility staff confirmed that R2 was administered the wrong dosage of Omeprazole for approximately three (3) months. Deficiency is being cited on LIC809-D. Failure to correct plan of correction could result in assessed civil penalties. Exit Interview and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 31, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This regulation has not been met as evidenced by: Facility staff failed to ensure R2’s medication dosage was correctly documented resulting in R2 being administered the wrong dosage for 3 months which posses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jan 17, 2025

Plan of correction: The facility shall submit a plan that addresses charting and documenting medication changes timely. Staff shall be trained on the implemented plan. Plan of correction shall be submitted by 01/31/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Adam Hill during today's inspection. LPA arrived to discuss two separate incident reports received from the facility. LPA interviewed administrator concerning incident. Administrator will follow up on information with staff and follow up with LPA. At this time, no deficiencies cited during today's inspection. Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 25, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Adam Hill during today's inspection. LPA arrived to discuss two separate incident reports received from the facility. LPA interviewed administrator and staff concerning incident and obtained resident documents. It appears facility followed proper protocol and regulation on each incident that occurred. No deficiencies cited during today's inspection. Exit interview conducted.the state’s words, verbatim · CDSS document, May 2, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA arrived to the facility and met with Administrator Adam Hill and Tricia Diaz. Facility sent an incident report into CCL concerning an incident that occurred on 3/28/24. LPA interviewed administrator concerning incident and obtained resident documents. No deficiencies cited during today's inspection. Exit interview conducted.the state’s words, verbatim · CDSS document, Apr 2, 2024

Type of visit: Case Management - Other

On March 6, 2024, Licensing Program Analysts (LPA) Bethany Mirlohi and Talwinder Bains conducted a case management visit to follow up on a case management visit conducted at the facility on February 2, 2023. LPA Bethany Mirlohi and Talwinder Bains met with Tricia Diaz and explained the purpose of the visit. On February 2, 2023, the Department concluded an investigation from a self-reported incident that occurred where R1 sustained a fall at the facility on June 6, 2022, which resulted in R1s death at the hospital on the same day. R1’s death certificate indicates R1’s “Cause of Death” as Acute Subdural Hematoma with Shift, Mechanical Fall, Acute Respiratory Failure, and Acute Cardiac Arrest; and states R1 suffered an unwitnessed, ground level fall. The licensee was cited for California Code of Regulations (CCR), Title 22 Division 6, Chapter 8, § 87464(f)(1) states in part, “Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). At the time of the Case Management visit on February 2, 2023, an immediate civil penalty in the amount of $500 was issued, and the license was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49. Continuation on 809-C. 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 as facility management’s failure to reappraise R1 after R1 suffered five unwitnessed falls in a two-month period, the final fall resulting in R1’s death. The facility should have implemented enhanced care and supervision to mitigate the resident's risk of falls. Today, March 6, 2024, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(d) in the amount of $15,000 for a violation that the Department determines resulted in the death of a resident. However, since an immediate civil penalty of $500 was previously issued on February 2, 2023, the amount of the civil penalty issued today will be $14,500. A copy of the LIC 421D was given to the facility representative. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Tricia Diaz signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Mar 6, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual inspection. LPA met with Administrator Adam Hill upon arrival. Currently there are 98 residents of which 14 residents are receiving hospice care. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 10 resident files and 10 staff files. LPA reviewed 4 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA observed a copy of current liability insurance. LPA observed not all care staff had updated CPR and first aid certificates. Deficiencies are cited on 809-D. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 3, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management inspection. LPA met with Administrator Adam Hill and Tricia Diaz, Resident Care Coordinator. LPA received a report from the facility concerning an incident that occurred on 9/11/23. R1 was a memory care resident and was found outside of the facility on the facility patio by staff. Facility investigated the incident and found that a caregiver had let R1 out of the memory care unit due to a misunderstanding. R1 was immediately brought back to the memory care unit and responsible party was notified. Administrator stated training was provided to care staff the following day. Due to the information gathered, deficiencies are cited on 809-D. Appeal rights provided. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 2, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 3, 2023

87411 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 records of the incident of R1 AWOL from the facility memory care unit on 09/11/23. This posed a potential risk to the resident.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: Administrator provided training on 9/12/23 to care staff in the memory care unit. LPA was provided the training that was completed. POC cleared and letter of clearance provided.