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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002415
Report Date: 08/31/2020
Date Signed: 08/31/2020 11:31:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:EAGLE LAKE VILLAGEFACILITY NUMBER:
185002415
ADMINISTRATOR:HOLLERAN, MARIAFACILITY TYPE:
740
ADDRESS:2001 PAUL BUNYAN RDTELEPHONE:
(530) 257-6673
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:76CENSUS: 33DATE:
08/31/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Holleran; AdministratorTIME COMPLETED:
12:00 PM
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On 8/31/2020 at 10 AM, Licensing Program Analyst (LPA) Cheng conducted an announced Case Management Health and Safety visit via Facetime and spoke to Administrator Maria Holleran. A Facetime video call was made in compliance with the department's COVID-19 procedures. LPA explained reason for visit and toured the facility inside and out including but not limited to facility kitchen, dining area, outside area, hallways, and resident rooms. All rooms were fully furnished and had sufficient lighting. Outside area is free of obstruction and bodies of water. Facility has a 7-day non-perishable and 2-day perishable food supply along with a separate emergency food supply. Medications are centrally stored in a locked room that is only accessible by key. Facility hot water temperature measured at 110 degrees Fahrenheit.

Smoke and carbon monoxide detectors were observed as operational. Fire drill was last conducted on 8/31/2020 and is conducted on a monthly basis. Fire extinguisher was last inspected on 3/19/2020. Facility sprinkler system was last inspected on 8/28/2019. Facility's Memory Care Units delayed egress system is checked weekly.

No deficiencies observed and an exit interview was conducted.

A copy of report was given via e-mail and a signed copy was mailed back.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020
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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