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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002415
Report Date: 08/06/2021
Date Signed: 08/06/2021 04:26:07 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: 32DATE:
08/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Holly Suiter; Resident Care CoordinatorTIME COMPLETED:
04:45 PM
NARRATIVE
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On 8/6/2021, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management visit as directed by the department and met Resident Care Coordinator Holly Suiter. Prior to initiating the 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 by facility's automated screening system.

The purpose of this visit was to issue a $100 civil penalty for facility failing to have S1 associated to the facility and receive a California Criminal Background Clearance prior to providing any services. S1 was in the facility on 1/16/2020 and assisting with medication review in the facility's eMAR system. According to complaint #25-AS-20200219155612 that was conducted by LPA Cheng, complaint documents confirmed that S1 was in the facility reviewing, making changes, and instructing med staff to administer medications. A civil penalty of $100 is issued for CCR 87355(e)(1).

Deficiency cited on LIC 809D.

Exit interview conducted and a copy of the report along with appeal rights were given.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2021
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by:
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Based on complaint investigation and statements obtained on 3/6/2020, Licensee did not associate 1 of 1 individuals which poses an immediate health and safety risk to all residents in care.
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If Licensee wisehs to allow S1 into the facility for medication review or any other services related to resident care, Licensee will have S1 obtained a criminal background clearance and associate S1 to the facility.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021
LIC809 (FAS) - (06/04)
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