185002877-2-19-2025-59-AS-LCRR-DE8R76-20250225114550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 185002877
Report Date: 02/19/2025
Date Signed: 02/19/2025 12:14:40 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
02/05/2025 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 59-AS-20250205153700

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: 63	DATE:	02/19/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Anthony Faulkner		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff did not dispense medications as prescribed
Facility staff did not assist resident with medication refill

INVESTIGATION FINDINGS:

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On February 19, 2025 at approximately 10:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Eagle Lake Village for the purpose of conducting a subsequent complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Anthony Faulkner, and was granted access into the facility.

During the course of the investigation, LPA conducted interviews with staff, Resident #1 and a Witness. In addition, the LPA reviewed the Medication Administration Record for the date in question, reviewed the Care Notes from January 1, 2025 through February 17, 2025, and reviewed the Call Bell Log from January 20, 2025 through February 19, 2025. LPA toured the facility on February 10, 2025 and made observations.

Complaint alleges that Facility staff did not dispense medications as prescribed. Based on interviews that were conducted and observations of facility documents and resident records, LPA could not prove or disprove the allegation occurred. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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 59-AS-20250205153700

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: 02/19/2025

NARRATIVE

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Furthermore, LPA reviewed the Medication Administration Record (MAR) for the date in question and found no evidence of missed medications for the alleged date. LPA reviewed the Care Notes from January 1, 2025 through February 17, 2025, which also revealed no concerns. On one Care Note dated for January 30, 2025, the resident reported that the staff never responded to the residents room when pushing the call bell for medication. LPA reviewed the call bell log for the date in question and learned that the facility response time was eight (8) minutes. LPA conducted interviews and received inconsistent statements. LPA could not corroborate the allegation.

Complaint alleges that Facility staff did not assist resident with medication refill. Based on interviews that were conducted with staff and an outside witness, LPA could not prove or disprove the allegation occurred. Furthermore, during interviews, LPA received inconsistent statements. LPA learned that the medication did run out and that the facility staff contacted the Nurse Practitioner for a refill which was refilled and picked up at the local pharmacy by the Residential Care Coordinator. LPA could not corroborate the allegation.

A finding that the complaint allegations of Facility staff did not dispense medications as prescribed and Facility staff did not assist resident with medication refills are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC9099 (FAS) - (06/04)

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