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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002877
Report Date: 08/16/2022
Date Signed: 08/16/2022 03:15:02 PM


Document Has Been Signed on 08/16/2022 03:15 PM - 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:
185002877
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:PrelicensingUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Holly Suiter, Administrator TIME COMPLETED:
01:00 PM
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on 08/16/2022, Licensing Program Analyst (LPA) Misty Valencia arrived at the facility for announced visit conduct visit regarding Pre-Licensing and Comp lll Orientation. LPA met with Holly Suiter, Administrator and explained the purpose of the visit. 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 Facility Representative and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA was screened at the front kiosk.

COMP II, has been completed by Centralized Application Bureau analyst who confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.

cont on 809-C

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)
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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: 185002877
VISIT DATE: 08/16/2022
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LPA toured the facility inside and out including but not limited to facility kitchen, dining room, living room, three (3) bathrooms, outside areas, and four (4) resident's rooms.

All resident rooms are fully furnished, and facility has sufficient activities available for clients. All bathrooms are equipped with hygiene products and paper towels. Exits and outside area are free of obstruction. There are no bodies of water present. There are no firearms being kept at the facility. Medications will be stored and locked in a locked cabinet/drawer in the locked medication room.

Smoke and carbon monoxide detectors were observed as operational. Fire extinguisher were observed as full. First aid kit was observed to be complete.



Facility is ready to be licensed by Centralized Application Bureau.

No deficiencies for todays visit. An exit interview was conducted and a copy of this report was emailed to Administrator.

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
LIC809 (FAS) - (06/04)
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