185002415-8-16-2022-25-AS-LMUZ-CHCNJY-20220816103108

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 185002415
Report Date: 08/16/2022
Date Signed: 08/16/2022 10:04:22 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2022 and conducted by Evaluator Misty Valencia

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220609153524

FACILITY NAME:	EAGLE LAKE VILLAGE		FACILITY NUMBER:	185002415
ADMINISTRATOR:	CROSS, VICKY		FACILITY TYPE:	740
ADDRESS:	2001 PAUL BUNYAN RD		TELEPHONE:	(530) 257-6673
CITY:	SUSANVILLE	STATE: CA	ZIP CODE:	96130
CAPACITY:	76	CENSUS: 36	DATE:	08/16/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Holly Suiter Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Administrator is not qualified
Facility not providing documents to Ombudsman

INVESTIGATION FINDINGS:

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On 08/16/2022 Licensing Program Analyst (LPA) MIsty Valencia conducted an unannounced complaint investigation visit regarding the above allegations and deliver the report findings. LPA met with Jennifer Cutler Business Office Manager (BOM) and Holly Suiter Administrator. Prior to initiating the complaint visit, 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.

continued on 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220609153524

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EAGLE LAKE VILLAGE	FACILITY NUMBER: 185002415
	VISIT DATE: 08/16/2022

NARRATIVE

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The Department has investigated the following allegations; Administrator is not qualified and Facility not providing documents to Long Term Care Ombudsman (LTCO) and have concluded that the allegations are to be Unfounded. Through records reviewed, it was determined that the Administrator is qualified and has been associated to the facility. Administrator also provides the LTCO with any and all required documents that LTCO are required to have and have permission to receive.

This agency has investigated the above listed complaint allegations. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

There were no citations issued during today's visit. An exit interview was conducted with Administrator and copy of the report emailed..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC9099 (FAS) - (06/04)

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