Basic services and supervision
Cited in 5 reports, with 5 deficiencies in total.
ESKATON GOLD RIVER LODGE
11390 COLOMA RD, Gold River CA 95670
134 bedsLatest official report Aug 12, 2026Licensed
Additional info
- Telephone
- (916) 852-7900
- Licensee
- ESKATON
- Administrator
- ALFREDO CRUZ
- Contact
- ALFREDO CRUZ
- License first date
- Jun 10, 1999
- License effective date
- Jun 10, 1999
- District office
- SACRAMENTO SOUTH ASC · (916) 263-4700
- Regional office
- 27
- Clients served
- 983 - RCFE / DEMENTIA
Summary
The available records show 21 Type A and 11 Type B deficiencies for this facility.
- Most recent inspection
- Aug 12, 2026
- Most recent deficiency
- Mar 5, 2026
5 later reports, from Mar 9, 2026 through Aug 12, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 48 Sacramento County facilities licensed for 50 or more beds.
In the available public five-year record, CCLD published 46 reports for this facility: 23 inspections, 23 complaint investigations, and 0 licensing or administrative records.
Those records contain 21 Type A and 11 Type B deficiencies.
4 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 23
- Recorded deficiencies
- 32
- Type A deficiencies
- 21
- Type B deficiencies
- 11
- Substantiated complaints
- 9
- Repeated topics
- 4
More than the typical 12
3 in the last 12 months
Well above the typical 8
1 in the last 12 months
Well above the typical 4
0 in the last 12 months
Well above the typical 5
1 in the last 12 months
Well above the typical 3
2 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Staffing, personnel, and training
Cited in 3 reports, with 5 deficiencies in total.
Background checks
Cited in 2 reports, with 3 deficiencies in total.
Resident rights
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 3 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87468.1 Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: Based on interviews and record review, Licensee did not ensure a dignified relation between a staff member and resident in care regarding care procedures. This posed a potential health, safety, and resident rights risk to residents in care.
Official plan of correction
Licensee will ensure completed staff training on resident rights. Training to include but not be limited to Section 87468.1(a)(3). Proof of completed training to be submitted to LPA by POC due date.
Deadline recorded: Mar 16, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 16, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 1 unsubstantiated · 0 unfounded · 2 cited
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87466
- Regulation authority
- CCR
What the official deficiency says
Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional... appropriate assistance is provided... The Licensee did not meet the above requirement when: Based on a review of records and interviews, staff became aware of R1 having a change in condition on 11/5/2024 and staff did not contact R1’s (PCP) when the change of condition was noted. This posed an immediate threat to the health, safety and personal rights of residents in care.
Official plan of correction
The Licensee hired a new Executive Director as of 12/05/24 and the new ED has held the team accountable with regard to reporting requirements and residents' change of condition. There is also a new Resident Care Director to oversee assessments, re-appraisals and family care conferences This POC has been cleared.
Deadline recorded: Aug 21, 2025. A deadline is not proof that correction was completed.
Official record says corrected or clearedOn or before Aug 20, 2025
Correction deadline recordedDeadline Aug 21, 2025
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.2(a)
- Regulation authority
- CCR
What the official deficiency says
Additional Personal Rights of Residents in Privately Operated Facilities (20) To be protected from involuntary transfers, discharges, and evictions... The Licensee did not meet the above requirement when: Based on a review of records and interviews, on 11/19/24, the RCC did not allow R1 to return to the facility when the hospital tried to discharge R1 so R1 could return home. This posed an immediate risk to the health, safety, and personal rights of residents in care.
Official plan of correction
The ED will communicate with residents and responsible parties Eskaton's policy regarding resident transfers and the use of mechanical lists. This will be accomplished though a recorded Family Meeting on 08/21/25. The agenda and link to the meeting will be forwarded to CCLASCPSacramentoRO@dss.ca.gov.
Deadline recorded: Aug 21, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 21, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87470(b)(2)
- Regulation authority
- CCR
What the official deficiency says
Infection Control Rqmts. 87470(b)(2) (b) In addition to ...with a contagious...(2) All staff ...Personal Protective Equipment (PPE) to prevent exposure to infectious agents... The licensee did not ensure the above regulation was enforced as evidenced by: Based on interviews with S2 and S3 along with this LPA's observations on 11/14/25, 3 staff members were not following the infection control protocol and were not wearing masks/PPE. This posed a potential threat to the health, safety, and/or personal rights of residents in care.
Official plan of correction
The ED stated that since the time of this complaint, addtional trainings on infection control procedures have taken place and staff who did not/do no follow those protocols have been/will be counseled and disciplined. ED will provide LPA with documentation showing the trainings and disciplianry actions that were conduted. This infomation will be submitted to CCL and a copy to the LPA at CCLASCPSacramentoRO@dss.ca.gov by close of business 6/06/25.
Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 6, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Administrator qualificationsType A
- Official classification
- Type A
- Official code
- 87405(b)
- Regulation authority
- CCR
What the official deficiency says
Administrator Qualifications (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement was not met as evidenced by: Based on interviews and records review, the Administrator did not ensure that the COVID-19 Preparedness and Response Plan was implemented. Residents were not tested upon move-in, additional testing was not conducted immediately on those who were in proximity of infected residents, and staff did not wear masks in communal areas. This posed an immediate risk to the heath, safety, and personal rights of residents in care.
Official plan of correction
Administrator will develop and submit a plan for conducting an inservice on idenitifying COVID symptoms in addtion to reviewing the COVID Preparedness and Response Plan. The plan for this inservice and an outline of what it will cover will be submitted to kimberly.viarella@dss.ca.gov by 9/18/24 and the trainings (for all care staff and leadership) will be completed by 10/11/24. Signature sheets will be submitted to CCL at the the aove email address.
Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 18, 2024
Correction not verified in available records
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(1)
- Regulation authority
- CCR
What the official deficiency says
Incidental Medical and Dental (a) ... incidental medical and dental care shall be developed by each facility... provide for assistance in obtaining such care ...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and a review of records, R1 was denied medical assistance when they requested a COVID test. This posed an immediate risk to the health, safety and personal rights of residents in care.
Official plan of correction
Administrator will arrange for an inservice for med techs on personal rights, the date of which will be submitted to CCL at the email above by 9/18/24. The training will be completed by 10/11/24 and signatures sheets will be submitted to CCL at the email above.
Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 18, 2024
Correction not verified in available records
Complaint
Allegations2 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Food serviceType B
- Official classification
- Type B
- Official code
- 97555(b)(9)
- Regulation authority
- CCR
What the official deficiency says
General Food Service-The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This was not met as evidenced by: Based on interviews, food was not being served at the appropriate temperature due to equipment malfunction, the placement of a fan over the hood in the kitchen, and staff not being trained to pace meals. This posed a potential threat to the health, safety and/or personal rights to residents in care.
Official plan of correction
The facility has repaired or replaced the faulty equipment, trained kitchen staff not to place food under the hood until it is time to be delivered, and trained server to pace meals. This plan of correction has already been met. This POC has been cleared.
Deadline recorded: Jul 17, 2024. A deadline is not proof that correction was completed.
Official record says corrected or clearedOn or before Jul 17, 2024
Plan of correction recorded
Correction deadline recordedDeadline Jul 17, 2024
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(d)(3)
- Regulation authority
- CCR
What the official deficiency says
(d) All personnel shall be given on the job training... provide knowledge of and skill in the following...as evidenced by safe and effective job performance: (3) ... to provide necessary resident care and supervision... The facility did not meet the above requirement as evidenced by: 2 out of 9 staff interviewed stated that employees were using the Hoyer lift by themselves and not requesting a second person to assist.
Official plan of correction
Designated Facility Administrator stated they will do additional training on Hoyer operation for Memory Care staff. The nursing staff will develop and conduct the training by 07/23/23. An outline of the training along with signature sheets will be submitted to CCL at kimberly.viarella@dss.ca.gov.
Deadline recorded: Aug 23, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 23, 2024
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 2 unsubstantiated · 0 unfounded · 3 cited · investigated over 2 visits
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87464(f)(1)
- Regulation authority
- CCR
What the official deficiency says
Basic Services: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by resident (R1) was witnessed on video leaving the facility at 7:30pm, the facility doors were locked while the resident was still outside walking their dog. As a result, the resident was not noticed as missing and was not discovered by staff until the following morning. The coroner’s determination of death for the resident is hypothermia. Per the facility plan of operation, supervision would include health checks for all residents at a minimum of every two hours. R1 and the facility had a no check agreement from 10pm until 6am. Per the facility’s plan of operation, R1 should have been checked on between the time they exited the facility until R1’s agreed upon no check time that exceed two hours and was not consistent with the facility’s own plan of operation which poses an immediate health safety and personal rights risk to residents in care.
Official plan of correction
facility will establish a documentation of resident whereabouts and confirm their presence at the facility at the beginning and end of each shift. facility will submit a written plan establishing the supervision of residents.
Deadline recorded: Feb 8, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 8, 2024
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Feb 7, 2024 · Control 27-AS-20230705114802
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87464(d)
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Facility will provide a written plan of correction by the POC date to incorporate a " red flag " system by where a resident with a change in condition is red flagged and is automatically placed on frequent checks until the resident is reasessed or a new care plan is put in place and the red flag is removed.
Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 17, 2023
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(b)
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Facility has agreed to conduct additional training on reporting requirements and provide evidence of topics discussed during the training and documentation training was received by all mandated reporters at the facility.
Deadline recorded: Nov 30, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 30, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 4 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(1)
- Regulation authority
- CCR
What the official deficiency says
Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's interviews with staff and self reported incident report that details how resident was given and additional dose of weekly medication which poses an immeated health, safety and personal rights risk to residents in care.
Official plan of correction
Facility will conduct retraining for staff identified as responsible for the medication error and provide documentation of medication administration training to the department by the POC due date.
Deadline recorded: Oct 24, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 24, 2022
Correction not verified in available records
Complaint
Allegations1 substantiated · 2 unsubstantiated · 1 unfounded · 2 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- HSC
What the official deficiency says
Personnel Requirements: 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 LPAs observation of camera recordings of the incident between R1 and R2 in a common area of the memory care unit where no staff were present to intervene and meet the needs of the resident which poses an immediate health and safety risk to residents in care.
Official plan of correction
Facility will provide the department with a written plan for routine surveillance and ensuring as staff presence and monitoring of residents to prevent further instances from reoccurring at the facility.
Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 25, 2022
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(1)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by multiple acts of aggression by R2 against R1 documented by the facility which poses a potential health and safety risk to residents in care.
Official plan of correction
Facility will provide the department with a written plan to address the steps facility will take to ensure resident safety when a resident displays an act of aggression towards another resident.
Deadline recorded: Mar 4, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 4, 2022
Correction not verified in available records
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology