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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 185002415
Report Date: 06/11/2020
Date Signed: 06/11/2020 03:45:23 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2020 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20200312084555
FACILITY NAME:EAGLE LAKE VILLAGEFACILITY NUMBER:
185002415
ADMINISTRATOR:DRUMMOND, LYNNFACILITY TYPE:
740
ADDRESS:2001 PAUL BUNYAN RDTELEPHONE:
(530) 257-6673
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:76CENSUS: DATE:
06/11/2020
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lynn Drummond; AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained a fracture while in care.
INVESTIGATION FINDINGS:
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On 6/11/2020 at 10:30 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation telephone call and met with Administrator Lynn Drummond. A telephone call was made in compliance to Governor Newsom's Proclomation regarding COVID-19. LPA explained reason for visit.

Based on interviews and documents obtained, LPA determined that there is not enough information. On the date of the incident, only S1 was in the memory care unit and during the NOC shift. S1 stated that S1 had just finished assisting another resident and was exiting the resident's room when S1 observed R2 push R1.

Continuation on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020
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 2
Control Number 25-AS-20200312084555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: EAGLE LAKE VILLAGE
FACILITY NUMBER: 185002415
VISIT DATE: 06/11/2020
NARRATIVE
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S1 stated to have been too far from R1 and R2 to make any attempt to save R1 from falling. R2 does have a past behavior of being combative but S4 stated that this behavior has not been happening in the past months. S4 has doubts that R2 could've pushed R1 but was not able to support it with any statements and also that S4 was not there when the incident occurred.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Two copies of the report was sent and LPA requested for one signed copy to be sent back for filing.

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2