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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002415
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:58:21 AM


Document Has Been Signed on 08/16/2022 11:58 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:SUITER, HOLLYFACILITY TYPE:
740
ADDRESS:2001 PAUL BUNYAN RDTELEPHONE:
(530) 257-6673
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:76CENSUS: 36DATE:
08/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Holly Suiter, AdministratorTIME COMPLETED:
01:00 PM
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
Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced case management visit and met with Holly Suiter, Administrator. Today’s visit is regarding an incident report (date of 7/11/22) submitted to licensing on 07/12/2022 where client (R1) choked on a piece of chicken in his own room.

An interview was conducted with Admin, who reported that the choking incident is common with a diagnosis of dysphagia. R1 was taken to ER for further assessment because R1 had breathing issues. R1 was evaluated and returned back to the facility that same day. Appointment with the primary physician (PP) on 08/02/22 had no changes in diet or medications. R1 is on constant alert charting especially during meal times.

It appears the facility acted within the doctor's orders, R1 was not on any food restrictions or special diets and no changes from the PP.

No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was emailed to Admin.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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