Inspection visit

Follow-up on correctionsNovember 16, 2023

ESKATON GOLD RIVER LODGELicense 3470012412 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

This report is being amended to include required information that was omitted by LPA in order to meet department standards of required information including who LPA met with during the inspection. Licensing Program Analyst (LPA) Kevin Gould made an unannounced Case Management inspection to the Eskaton Gold River Lodge (RCFE) on 11/16/23 at 9:00am to address concerns observed during a complaint investigation. LPA met with Lynn Perena and together discussed the department’s concerns and observations. Based on statements obtained during the department’s investigation of an assigned complaint the department has determined there is a preponderance of evidence to support multiple staff members including outside caregivers discussed or expressed concerns with a decline in resident’s cognitive abilities, short term memory and orientation of time and place. Three care providers who interacted with R1 on a regular basis provided statements to the department observing confusion and cognitive decline of R1. Two of the three interviewed described confusion related to facility orientation. Two staff members interviewed provided statements that R1’s mental decline was a topic of discussion in “stand up” meetings among staff members. The latest Physician report dated October 2022 did not include any mention of dementia or MCI. Other documentation observed post physicians report include: additional confusion, wandering and looking for 5 dogs (resident only had one at the facility). All documentation and statements were given prior to the resident care meeting with authorized representatives where memory care placement was discussed but no evaluation was conducted to ensure resident’s needs were met by facility staff. Department interviews and review of surveillance footage with morning shift staff present on the date Resident was discovered outside the building, observed resident’s dog in the parking lot unattended at approximately 4:58am. Facility staff interview indicate facility staff were not notified by arriving staff member until 5:20am and resident was discovered outside the building at approximately 5:23am. The department has concluded the staff members present did not display competency in the required duties for care and supervision of resident as resident’s animal was observed unsupervised and resident was not checked on immediately to ensure the resident’s health and safety. Per California Code of Regulations, Title 22, the following deficiencies are cited. Exit interview conducted and a copy of this report and appeal rights were left at the facility.

Citations

4 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87211(b)Type B
Reporting Requirements: Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1) Which poses a potential Health, safety and personal rights risk to residents in care.
87464(d)Type A
Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-Admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by a care meeting taking place with resident, their authorized representatives and facility staff where resident’s increased medical needs and physical decline was discussed. Despite the admission of a change of condition and increased medical needs, no changes to the resident’s care plan or increased supervision were established which poses an immediate health, safety, or personal rights risk to residents in care.
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87411(a)Type A
Personnel Requirements – General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by staff actions when encountering a known resident’s dog unattended, no staff member checked on resident for over 20 minutes prior to being discovered in the front of the building and did not display competency in their job performance by not checking on resident who was in a stated of distress which poses an immediate health, safety and personal rights risk to residents in care.
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87466Type B
Observation of Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by statements by facility and outside care providers and documentation of concerns of Resident cognitive decline prior to the last resident care meeting with authorized provider and the resident’s death which poses a potential health, safety, and personal rights risk for residents in care.
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FAQ · About this visit

Common questions about this visit

What happened during the November 16, 2023 inspection of ESKATON GOLD RIVER LODGE?

This was a other inspection of ESKATON GOLD RIVER LODGE on November 16, 2023. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to ESKATON GOLD RIVER LODGE on November 16, 2023?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "Reporting Requirements: Any suspected physical abuse that results in serious bodily injury of an elder or dependent adul..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

Follow-up on corrections·November 16, 2023