Eskaton Village.

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.

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.

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.

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.

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.

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.

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.

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.

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.