185002877-10-4-2022-25-AS-APEZ-CK3RXG-20221010132443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 185002877
Report Date: 10/04/2022
Date Signed: 10/04/2022 10:50:06 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2022 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20220928151005

FACILITY NAME:	EAGLE LAKE VILLAGE		FACILITY NUMBER:	185002877
ADMINISTRATOR:	SUITER, HOLLY		FACILITY TYPE:	740
ADDRESS:	2001 PAUL BUNYAN RD		TELEPHONE:	(530) 257-6673
CITY:	SUSANVILLE	STATE: CA	ZIP CODE:	96130
CAPACITY:	76	CENSUS: 36	DATE:	10/04/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	HOLLY SUITER		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility staff did not allow spouse to visit resident.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact and met with Holly Suiter, Administrator. It was alleged that Facility staff did not allow spouse to visit resident.

LPA Gurriere 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/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220928151005

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EAGLE LAKE VILLAGE	FACILITY NUMBER: 185002877
	VISIT DATE: 10/04/2022

NARRATIVE

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Facility staff did not allow spouse to visit resident.
During the investigation, two staff persons and two residents (Resident 1 and Resident 2) were interviewed., Both residents, (husband and wife) reside in the facility. Documents were obtained and include Admission Agreements, Physician’s Reports and Assessment documents.

During the interview process, it was stated that a Resident 1 was concerned that he does not always get to spend time with Resident 2, as she is in memory care. Staff persons advised that the only time Resident 1 could not visit with Resident 2 was when Resident 2 had another visitor visiting for several hours. Resident 1 confirmed that generally he gets to visit with Resident 1. It was reported that Resident 1 and Resident 2 spend time with each other in his apartment, throughout the day and evening, which includes mealtimes. It was reported that Resident 1 would like to get a schedule of the activities so that he and Resident 2 can attend the activities together. The administrator agrees to provide a calendar of the activities to Resident 1.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

LIC9099 (FAS) - (06/04)

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