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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002415
Report Date: 10/05/2021
Date Signed: 10/05/2021 02:55:53 PM

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:CROSS, VICKYFACILITY TYPE:
740
ADDRESS:2001 PAUL BUNYAN RDTELEPHONE:
(530) 257-6673
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:76CENSUS: 33DATE:
10/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 AM
MET WITH:Vicky CrossTIME COMPLETED:
02:45 PM
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Dawn Keane, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident. LPA Keane met with Assistant Executive Director (ADE) Holly Suiter.

LPA Keane completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Keane ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask/ Surgical Mask. Additionally, LPA Keane was screened by administrator/staff person upon entering the facility.

On 09/04/21 it was reported that a resident (Resident 1) was found on the floor in the resident’s apartment near the bathroom sink. The staff noticed a bump on the back of the resident’s head and called Emergency Services (911). Emergency Services arrived and the resident was transported to the hospital. The resident required three staples to the back of the head. The resident was returned to the facility.

It was reported that the resident is doing well and that this type of incident will be avoided in the future, as the resident was moved to a room that is closer to front desk and med tech office so that staff can help resident if needed..

An exit interview was conducted, and a copy of the report was given to the administrator. No deficiencies cited.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Dawn KeaneTELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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