Inspection Reports for Eskaton Village Roseville
1650 Eskaton Loop, Roseville, CA 95747, United States, CA, 95747
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent follow-up on June 17, 2025, which found no issues related to a reported resident death. Earlier reports included a few deficiencies, with the most serious involving a resident’s death linked to inadequate fall supervision in early 2023, resulting in a $14,500 fine. Other cited issues involved a medication documentation error in January 2025 and a substantiated complaint in November 2023 about insufficient staffing in the memory care unit. Several complaint investigations were unsubstantiated, including concerns about cleanliness, resident care, and facility conditions. The facility appears to have improved over time, with recent inspections showing no deficiencies and effective responses to prior concerns.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 77
Capacity: 125
Deficiencies: 0
Jun 17, 2025
Visit Reason
The visit was conducted as a case management follow-up regarding a death report for a non-hospice death at the facility.
Findings
The facility investigated the death report and did not find any suspicious circumstances. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Mikkelson | Licensing Program Analyst | Arrived at the facility to follow up regarding a death report and conducted the inspection. |
| Danielle Peck | Executive Director | Met with Licensing Program Analyst during the inspection and exit interview. |
| Alicia Rist | Administrator/Director | Named as facility administrator/director in the report header. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 125
Deficiencies: 0
May 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including unclean and unsanitized resident rooms, malodorous rooms, unmet toileting and hygiene needs, and presence of mold in the kitchen.
Findings
The investigation found all allegations to be unsubstantiated or unfounded after interviews, facility tours, and document reviews. Resident rooms were found clean and sanitized, no odors were detected, residents' toileting and hygiene needs were met, and no mold was observed in the kitchen.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not ensuring clean and sanitized rooms, malodorous rooms, unmet toileting and hygiene needs, and mold in the kitchen. The investigation concluded that there was insufficient evidence to prove the allegations.
Report Facts
Facility capacity: 125
Resident census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
| David Dingcong | Facility representative met during the investigation | |
| Alicia Rist | Administrator | Facility Administrator present during exit interview |
Inspection Report
Census: 87
Capacity: 125
Deficiencies: 0
Feb 26, 2025
Visit Reason
The visit was a case management incident follow-up to review issues related to resident R2's blood sugar levels and an incident involving financial abuse of Resident #1 by a nail salon vendor.
Findings
The facility followed proper protocols regarding the blood sugar incident, and new policies and consent forms were implemented following the financial abuse incident. No deficiencies were cited at this time.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay DeVault | Business Manager | Met with LPAs during case management visit and discussed new policies and consent forms. |
| Alicia Rist | Executive Director | Participated by phone in review of new policies and consent forms related to financial abuse incident. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 125
Deficiencies: 0
Feb 4, 2025
Visit Reason
The visit was conducted to gather additional information regarding an unusual incident/injury report about financial abuse of Resident #1 by the nail salon services, which was reported to Community Care Licensing on 2025-01-27.
Findings
The Licensing Program Analyst interviewed the Business Office Manager and reviewed relevant documents. It was revealed that the facility filed a police report and suspended the nail salon services with the outside vendor. No deficiencies were cited at this time.
Complaint Details
The complaint involved financial abuse of Resident #1 by the nail salon services over about a year. The facility filed a police report and suspended the vendor services.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the case management visit and investigation. |
| Kay DeVault | Business Office Manager | Interviewed regarding the financial abuse incident and vendor services. |
| Adam Hill | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Annual Inspection
Census: 90
Capacity: 125
Deficiencies: 0
Jan 23, 2025
Visit Reason
The visit was an unannounced annual inspection conducted to ensure the health and safety of residents in care at Eskaton Village Roseville facility.
Findings
The Licensing Program Analyst toured multiple areas of the facility and reviewed resident and staff files, medication orders, and drill logs. No immediate health, safety, or personal rights violations were observed, and no deficiencies were found during the full care tool assessment.
Report Facts
Residents receiving hospice care: 17
Resident files reviewed: 10
Staff files reviewed: 10
Resident medications reviewed: 4
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Rist | Interim Executive Director | Met with Licensing Program Analyst during inspection and facility representative |
| Cheyenne Ratajczak | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Complaint Investigation
Capacity: 125
Deficiencies: 1
Jan 17, 2025
Visit Reason
The visit was a case management inspection regarding two LIC 624 reports sent to the Community Care Licensing (CCL) department, including a resident hospitalization and death, and a medication error involving incorrect dosage administration.
Findings
The investigation found that one resident (R1) passed away due to pneumonia with no further follow-up needed. Another resident (R2) was administered the wrong dosage of Omeprazole for approximately three months due to failure to update the Medication Administration Records, resulting in a cited deficiency.
Complaint Details
The visit was complaint-related based on two LIC 624 reports: one regarding resident R1's hospitalization and death, and another regarding a medication error for resident R2. The medication error deficiency was cited on LIC809-D. No further follow-up was needed for the resident death report.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to ensure R2’s medication dosage was correctly documented resulting in R2 being administered the wrong dosage for 3 months which poses a potential health risk to residents in care. |
Report Facts
Plan of Correction Due Date: Jan 31, 2025
Duration of Medication Error: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Diaz | LVN RCC | Spoke about medication error and resident care during inspection |
| Laura Munoz | Licensed Program Manager | Conducted case management visit and signed report |
| Cassandra Mikkelson | Licensed Program Analyst | Conducted case management visit and signed report |
Inspection Report
Census: 92
Capacity: 125
Deficiencies: 0
Jul 25, 2024
Visit Reason
The inspection visit was an unannounced case management visit to discuss two separate incident reports received from the facility.
Findings
No deficiencies were cited during the inspection. The administrator was interviewed and will follow up with staff and the Licensing Program Analyst regarding the incidents.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during inspection and interviewed concerning incident reports. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit and interviewed the administrator. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 93
Capacity: 125
Deficiencies: 0
May 2, 2024
Visit Reason
The inspection was an unannounced case management visit to discuss two separate incident reports received from the facility.
Findings
The facility followed proper protocol and regulation on each incident that occurred. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during the inspection and discussed incident reports. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit and inspection. |
Inspection Report
Census: 95
Capacity: 125
Deficiencies: 0
Apr 2, 2024
Visit Reason
The visit was an unannounced case management visit conducted following an incident report submitted by the facility concerning an incident that occurred on 2024-03-28.
Findings
No deficiencies were cited during the inspection. The Licensing Program Analyst interviewed the administrator and reviewed resident documents related to the incident.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during the case management visit and interviewed concerning the incident. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit and interviewed the administrator. |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 96
Capacity: 125
Deficiencies: 1
Mar 6, 2024
Visit Reason
The visit was a case management follow-up conducted on March 6, 2024, to follow up on a previous case management visit from February 2, 2023, related to an investigation of a resident's fall resulting in death.
Findings
The Department determined that a civil penalty was warranted due to the facility's failure to reappraise a resident after multiple unwitnessed falls, which resulted in the resident's death. A civil penalty of $14,500 was issued on March 6, 2024, in addition to a prior $500 penalty.
Deficiencies (1)
| Description |
|---|
| Failure to provide adequate care and supervision as required by CCR Title 22 Division 6, Chapter 8, § 87464(f)(1), resulting in a resident's death after multiple unwitnessed falls. |
Report Facts
Civil penalty amount: 14500
Immediate civil penalty amount: 500
Number of unwitnessed falls: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Diaz | Resident Care Coordinator | Met with Licensing Program Analysts during the visit and acknowledged appeal rights |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Talwinder Bains | Licensing Program Analyst | Conducted the case management visit |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 98
Capacity: 125
Deficiencies: 1
Jan 3, 2024
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate the health and safety of residents in care at Eskaton Village Roseville.
Findings
The inspection found no immediate health, safety, or personal rights violations in the areas toured. However, deficiencies were cited related to staff CPR and first aid certification compliance.
Deficiencies (1)
| Description |
|---|
| Licensee did not comply with the requirement that at least one staff member on duty have current CPR and first aid training, with 9 out of 38 staff lacking updated certificates. |
Report Facts
Staff non-compliance count: 9
Residents receiving hospice care: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during inspection and agreed to plan of correction |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Troy Ordonez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 125
Deficiencies: 1
Nov 2, 2023
Visit Reason
The inspection was an unannounced case management visit triggered by a reported incident where a memory care resident (R1) was found outside the facility patio due to a caregiver error.
Findings
The facility investigation confirmed that a caregiver mistakenly let the resident out of the memory care unit, posing a potential risk. Training was provided to staff following the incident, and deficiencies were cited related to personnel requirements.
Complaint Details
The visit was complaint-related due to an incident involving a memory care resident found outside the facility. The complaint was substantiated as deficiencies were cited.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements - 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, posing a potential risk to the resident. | Type B |
Report Facts
Census: 102
Total Capacity: 125
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during inspection and provided information about the incident and staff training |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management inspection and authored the report |
| Troy Ordonez | Licensing Program Manager | Supervisor overseeing the inspection and cited deficiency |
| Tricia Diaz | Resident Care Coordinator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 125
Deficiencies: 0
Aug 31, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-06-06 regarding multiple allegations about resident care and facility conditions.
Findings
The Licensing Program Analyst investigated four allegations related to timely staff response, proper food service, ability to meet resident care needs, and facility doors posing hazards. After interviews with residents, staff, and file reviews, all allegations were found to be unfounded.
Complaint Details
The complaint included allegations that staff do not attend to residents in a timely manner, do not provide proper food service, are unable to meet resident care needs, and that facility doors pose a hazard. All allegations were investigated and found to be unfounded.
Report Facts
Capacity: 125
Census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 125
Deficiencies: 3
Feb 2, 2023
Visit Reason
The visit was a case management inspection conducted due to an incident involving resident R1 who sustained multiple falls, including a fatal fall on 06/06/2022, which contributed to R1's death.
Findings
The investigation found that facility staff were aware that R1 was a fall risk but did not provide adequate care or supervision, nor reassessed R1's needs after multiple falls and health decline. The facility failed to implement a plan to mitigate fall risks, contributing to R1's death.
Complaint Details
The visit was triggered by a complaint and incident reports related to multiple falls sustained by resident R1, culminating in a fatal fall on 06/06/2022. The Department substantiated that the fall contributed to R1's death.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility did not reassess R1 for unmet needs despite multiple falls incidents in May and June 2022, posing immediate health and safety risks. | Type A |
| Facility did not document a reappraisal for R1 after identifying decline and multiple falls within a two-month period. | Type A |
| Facility did not provide proper care and supervision for R1, resulting in R1's fall and death on 06/06/2022. | Type A |
Report Facts
Civil penalty amount: 500
Number of falls: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during the visit and mentioned in relation to facility management's response to R1's care. |
| Talwinder Bains | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Laura Munoz | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Annual Inspection
Census: 87
Capacity: 125
Deficiencies: 0
Jan 24, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure the health and safety of residents in care.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during the inspection. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the annual inspection. |
| Troy Ordonez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 125
Deficiencies: 0
Aug 25, 2022
Visit Reason
The inspection was an unannounced case management visit to follow up on a recent AWOL incident involving resident R1 and multiple fall incidents involving residents R2 and R3 at the facility.
Findings
The facility submitted incident reports for the AWOL and fall incidents, notified doctors and families accordingly, and increased monitoring of affected residents. No citations were issued, only a Technical Advisory was given. The facility is actively addressing and implementing measures to prevent future incidents.
Complaint Details
The visit was complaint-related, following up on an AWOL incident for resident R1 and fall incidents for residents R2 and R3. The AWOL incident was the first for R1 and was uninjured. Fall incidents for R2 and R3 did not result in remarkable injuries. Monitoring and reporting measures were increased.
Report Facts
Incident reports: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Administrator | Met with Licensing Program Analyst during the inspection and involved in incident follow-up |
| Talwinder Bains | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Laura Munoz | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Annual Inspection
Census: 81
Capacity: 125
Deficiencies: 0
Dec 15, 2021
Visit Reason
An unannounced annual visit was conducted using the infection control tool to ensure health and safety of residents in care.
Findings
No immediate health, safety, or personal rights violations were observed. The facility was found to be in substantial compliance with infection control requirements and no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hill | Facility Administrator | Met with Licensing Program Analyst during inspection and explained the purpose of the visit. |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced annual visit using the infection control tool. |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 125
Deficiencies: 0
Jun 7, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that residents' needs were not being met because of lack of staff during July 2020.
Findings
The investigation included interviews with the previous and current administrators, resident care coordinator, and staff, as well as review of resident assessments and logs. The allegation was found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that residents' needs were not being met due to lack of staff. The findings were unsubstantiated as staff indicated the allegation was untrue and residents' needs were always met despite occasional staffing shortages.
Report Facts
Capacity: 125
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation |
| Adam Hill | Administrator | Met with during investigation; reported not working during time of allegation |
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