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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002415
Report Date: 12/03/2021
Date Signed: 12/03/2021 10:52:40 AM

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: 46DATE:
12/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Holly Suiter, Executive DirectorTIME COMPLETED:
11:00 AM
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On 12/03/2021 Licensing Program Analysts (LPAs) Dawn Keane and Misty Valencia conducted an announced visit to the facility and met with Executive Director (ED) Holly Suiter. The purpose of this visit was to conduct a case management visit due to an un-associated staff member. Before entering the facility, LPAs 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Masks.

LPA Keane explained to ED that all staff on facility grounds are required to have a background clearance prior to working in facility. ED reported that the facility was already cited regarding this incident on 08/06/2021. LPA confirmed that criminal background clearance was cited on that date by LPA Cheng.

ED understand all staff are required to have a criminal records clearance before working on the facility grounds.

As a result of this visit, no deficiencies cited, exit interview conducted copy of report left at the facility.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Dawn KeaneTELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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