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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002415
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:00:12 PM


Document Has Been Signed on 08/16/2022 12:00 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:EAGLE LAKE VILLAGEFACILITY NUMBER:
185002415
ADMINISTRATOR:SUITER, HOLLYFACILITY TYPE:
740
ADDRESS:2001 PAUL BUNYAN RDTELEPHONE:
(530) 257-6673
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:76CENSUS: 36DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer Cutler Business Office Manager (BOM) and Holly Suiter Administrator (Admin)TIME COMPLETED:
01:00 PM
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On 08/16/2022 at 9:30 AM Licensing Program Analyst (LPA) Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA metLPA met with Jennifer Cutler Business Office Manager (BOM) and Holly Suiter Administrator and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff.

LPA and BOM toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3)resident bedrooms in assistant living and two (2) resident bedrooms in memory care, three (3) bathrooms, dining room, and storage rooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Admin completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection. Technical Assistance was provided.
Exit interview conducted and copy of report was emailed to Admin.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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