<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002415
Report Date: 04/05/2022
Date Signed: 04/05/2022 11:48:21 AM


Document Has Been Signed on 04/05/2022 11:48 AM - It Cannot Be Edited

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: 31DATE:
04/05/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Holly Suiter, Assistand Executive DirectorTIME COMPLETED:
11:42 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/5/22 at 10:35 a.m., Dawn Keane, Licensing Program Analyst (LPA) and Laura Munoz Licensing Program Manager (LPM) arrived at the facility unannounced to conduct a case management visit regarding TSP and incident reports. LPA Keane met with Assistant Executive Director (ED), 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 was contacted to complete a facility risk assessment. LPA Keane and LPM ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA Keane and LPM were screened at the kiosk at the front door.

An exit interview was conducted, and a copy of the report was given to the administrator.

No deficiencies cited.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Dawn KeaneTELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1