185002877-5-13-2024-59-AS-LCRR-D59T58-20240514142503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 185002877
Report Date: 05/10/2024
Date Signed: 05/13/2024 07:56:37 AM

Substantiated

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
05/08/2024 and conducted by Evaluator Sarah Benson

COMPLAINT CONTROL NUMBER: 59-AS-20240508091401

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: 49	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Anthony Faulkner Resident Care Coordinator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Medication Management.

INVESTIGATION FINDINGS:

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On 05/09/2024 at 11:00 AM Licensing Program Analyst (LPA) Sarah Benson, conducted an unannounced visit and met with Anthony Faulkner Resident Care Coordinator. The purpose of this visit was to open a complaint investigation. During today's visit the facility was toured, records were reviewed and interviews were performed.

LPA interviewed Anthony Faulkner Resident Care Coordinator and Denise Diaz medication technician. LPA requested the following documents during the visit: residents admission agreements, medical records, medication administration records, PRN records and incident reports.

(Continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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-20240508091401

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/13/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical... A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to conduct a medication training for all med techs concerning the requirement to ensure that residents do not run out of their medications and will provide LPA with training subject matter and sign in sheet with dates and staff signatures.
	8 9 10 11 12 13 14	Based on interviews and document review it was determined that R1 ran out of medications for at least a day.	8 9 10 11 12 13 14	In addition, licensee shall submit a plan to LPA that outlines the process that all med techs must follow to ensure that residents do not run out of medications.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240508091401

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: 05/10/2024

NARRATIVE

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Medication Management.

During the interview process it was reported the resident was out of seizure medication for at least a day. It was reported the resident had a seizure and was taken to the hospital. It was reported the hospital would not release the resident until the residents seizure medication was picked up from the pharmacy and available at the facility.

Upon review of Medication Administration Records it was discovered three days in the month of April on 4-11-24, 4-24-11 and 4-30-24 that no signature was recorded of medication administration and no notes explaining why the medication was not given.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to Anthony Faulkner Resident Care Coordinator.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

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