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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 185002877
Report Date: 05/01/2024
Date Signed: 05/01/2024 02:24:21 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2024 and conducted by Evaluator Jaynae Boyles
COMPLAINT CONTROL NUMBER: 59-AS-20240305143731
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: 49DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator- Jeffrey Dillon TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not keep the facility free from pest.
Resident sustained a pressure injury due to lack of care from staff.
Staff do not meet resident's toileting needs.
Staff do not meet resident's hygiene needs.
Staff are using nicotine products in the presence of residents.
Staff handled resident in a rough manner.
Staff yelled at residents.
INVESTIGATION FINDINGS:
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On 05/01/2024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with administrator. The purpose of this visit was to deliver the results of a complaint investigation.
During the course of the investigation the administrator and four (4) staff were interviewed. LPA reviewed the following documents: pest control service records, home health records for residents who are receiving wound care services, staff meeting notes for the last six months.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.
An exit interview was conducted. A copy of the report was provided to administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20240305143731
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: EAGLE LAKE VILLAGE
FACILITY NUMBER: 185002877
VISIT DATE: 05/01/2024
NARRATIVE
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LPA investigated, “Staff did not keep the facility free from pest”. Three of the four staff interviewed reported that there were pests in the facility. Staff reported that there were mice in the facility, and it was reported to the administrator who resolved the matter with urgency. A review of the records of pest control services indicate that the facility regularly receives pest control services. The licensee has a pest control company on contract that comes once a month. The facility property is rural. When the weather changes the rodents seek shelter from the rain/snow. LPA did not observe any rodent droppings during the tour and the Administrator stated she and the licensee are aware there are rodents around due to the location of the property and that is the reason for the pest control contract.

LPA investigated, “Resident sustained a pressure injury due to lack of care from staff”. According to the Administrator four residents receive wound care services from an outside agency. The administrator explained that the staff at the facility do not provide wound care for residents. Staff interviewed all reported that they do not provide wound care for residents. The staff and administrator reported to the LPA that if there is suspicion that a resident may have a pressure injury the resident is referred for wound care services immediately.

LPA investigated, “Staff do not meet resident's toileting needs”. Based on observations and interviews, it has been concluded that facility has adequate staff for all toileting needs. Furthermore, staff is providing assistance to residents with their toileting needs per their care needs with no issues.

LPA investigated, “Staff do not meet resident's hygiene needs”. Based on observations and interviews, it has been concluded that facility has adequate supplies for all hygiene supplies including soap, toilet paper and paper towels. Furthermore, staff is providing assistance to residents with their hygiene needs per their care needs with no issues.

LPA investigated, “Staff are using nicotine products in the presence of residents”. The administrator and four staff interviewed reported that no staff member has been seen using a nicotine product in the facility.

LPA investigated, “Staff handled resident in a rough manner”. The administrator and the staff have reported that no staff member has been observed to have been rough with a resident. The administrator reported that the facility has ongoing training to ensure that residents are handled with care when changing or transferring residents.

LPA investigated, “Staff yelled at residents”. The administrator and four staff interviewed reported that no staff member has been seen yelling at residents.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2