<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002877
Report Date: 09/04/2024
Date Signed: 09/04/2024 01:52:37 PM

Document Has Been Signed on 09/04/2024 01:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EAGLE LAKE VILLAGEFACILITY NUMBER:
185002877
ADMINISTRATOR/
DIRECTOR:		SUITER, HOLLYFACILITY TYPE:
740
ADDRESS:2001 PAUL BUNYAN RDTELEPHONE:
(530) 257-6673
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 76CENSUS: 60DATE:
09/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Prospective Administrator, Anthony FaulknerTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 4, 2024 at approximately 11:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Eagle Lake Village for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Prospective Administrator, Anthony Faulkner, and was granted access into the facility.

LPA and Prospective Administrator toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2024 at the time of the inspection. All smoke detectors sound directly to the fire station. Water temperature in facility measured at 106 degrees, within acceptable range of 105 to 120 degrees F. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Medication orders were reviewed. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. First Aid kit was inspected and found to be appropriate during the inspection.

LPA reviewed resident files and found that 2 out of 5 resident files did not have an updated LIC 602/Physician Assessment (See LIC 9102-Technical Violation). Prospective Administrator was under the impression that residents are supposed to be reappraised once every five years. LPA educated the Prospective Administrator and reviewed Regulation 87463(c)-Reappraisals. LPA reviewed staff files and found those to be appropriate. First Aid/CPR Card valid for staff that provide care and supervision to residents in care. LPA reviewed staff training and observed that 3 out of 5 staff members did not have the required training annually (See LIC 9102-Technical Violation). LPA educated the Administrator on the importance of every staff member shall have annual training as outlined in Title 22 regulation. (Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: EAGLE LAKE VILLAGE
FACILITY NUMBER: 185002877
VISIT DATE: 09/04/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
Updated Infection Control Plan
Most up-to-date Liability insurance
Emergency Disaster Plan
Control of Property
Register of residents

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4