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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 185002877
Report Date: 08/25/2025
Date Signed: 08/25/2025 04:38:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20250624144340
FACILITY NAME:EAGLE LAKE VILLAGEFACILITY NUMBER:
185002877
ADMINISTRATOR:FAULKNER, ANTHONYFACILITY TYPE:
740
ADDRESS:2001 PAUL BUNYAN RDTELEPHONE:
(530) 257-6673
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:76CENSUS: DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Shay Ewing - executive directorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not following physicians’ instructions.- UNSUBSTANTIATED
Staff did not ensure that resident is provided an adequate amount of water. - UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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08/25/2025 03:30 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Shay Ewing. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA conducted interviews and reviewed documents to include Service Plan, Over the counter PRN and First Aid Orders, MAR, Physician’s Report, care notes, for 1 resident, staff list with telephone numbers, resident list.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20250624144340
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/25/2025
NARRATIVE
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Page 2

Staff are not following physicians’ instructions. - UNSUBSTANTIATED

It was reported that resident's physician indicated that the facility needs to do a urine catch on Resident 1 (R1) to track how much R1 is urinating.

LPA reviewed R1’s Service Plan dated 01/16/2025 indicates that R1 manages their own medication and independently coordinates their own healthcare appointments. Physicians report states that R1 is able to manage their own medication with assistance from family.

LPA reviewed R1’s Over the counter PRN and First Aid Orders which includes Medication / Treatment: Urine collection/C+S if indicated. Instructions: UA and Culture to be collected as needed, for observed symptoms of a UTI. The facility does not have a physician’s order from R1’s doctor requesting the facility do a urine catch on R1 to track how much R1 is urinating.

R1 stated that they are asked for a urine sample when they are at the hospital, and every time they take a blood test.

Resident Care Coordinator stated that R1’s physician has not ordered a urine sample related to output but they do have a standing order in case or symptoms of UTI.

It was determined that the facility does not have a physician’s order from R1’s doctor requesting the facility do a urine catch on R1 to track how much R1 is urinating. This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250624144340
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/25/2025
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Page 3

Staff did not ensure that resident is provided an adequate amount of water. - UNSUBSTANTIATED

It was reported that that per R1’s physician, staff need to encourage R1 to drink water every two hours.

R1’s Service Plan dated 01/16/2025 indicates that R1 is independent with all activities of daily living and does not require assistance with meal reminders or feeding support. There is no physician’s order or notes on file at the facility requesting staff to encourage R1 to drink water every two hours.

On 06/25/2025 LPA observed a hydration station in the common area / dining room that contained large containers of water and lemonade with ice.

Resident interviews revealed that the facility has a hydration station and residents help themselves but staff do not offer water unless it is mealtime.

Resident Care Coordinator stated that R1 is very capable of drinking water throughout the day. RCC stated the facility has hydration carts located in the front and back of the facility. RCC stated that staff offer residents something to drink 3 or 4 times a day in rounding.

It was determined that R1 does not have a physician’s order or notes on file at the facility requesting staff to encourage R1 to drink water every two hours. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

An exit interview was conducted. A copy of the report was provided to facility Executive Director Shay Ewing.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3