185002877-8-25-2025-59-AS-LCRR-DLEMXS-20250911100025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 185002877
Report Date: 08/25/2025
Date Signed: 08/25/2025 04:35:19 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
05/16/2025 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20250516160354

FACILITY NAME:	EAGLE LAKE VILLAGE		FACILITY NUMBER:	185002877
ADMINISTRATOR:	FAULKNER, ANTHONY		FACILITY TYPE:	740
ADDRESS:	2001 PAUL BUNYAN RD		TELEPHONE:	(530) 257-6673
CITY:	SUSANVILLE	STATE: CA	ZIP CODE:	96130
CAPACITY:	76	CENSUS: 62	DATE:	08/25/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Carrie Breaux - RCC		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident assaulted another resident. - UNSUBSTANTIATED
The Administrator is not available for residents to speak to when they have concerns about the facility. - UNSUBSTANTIATED
Resident is not being properly supervised causing other residents to feel unsafe. - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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08/25/2025 03:00 pm Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with RCC Carrie Breaux. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA conducted interviews and reviewed documents including related incident report, change of administrator documents, staff schedules.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

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 3

Control Number 59-AS-20250516160354

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: 08/25/2025

NARRATIVE

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Resident assaulted another resident – UNSUBSTANTIATED.

LPA reviewed SOC341 reporting that R1 assaulted R2.

All staff who were interviewed stated they did not witness the incident.

Resident Care Coordinator stated that two residents were in an altercation and a police report was filed. Resident 1 could be loud and aggressive and would complain about other residents.

It was determined that this incident did occur and was reported by the facility to licensing and local law enforcement. However, there is no regulation that has been violated and as a result a citation cannot be issued for this allegation.

The Administrator is not available for residents to speak to when they have concerns about the facility. - UNSUBSTANTIATED

LPA reviewed, approved and submitted documents to change the administrator for the facility.

Residents who were interviewed stated the Executive Director was not at the facility very often but they were available to residents when they were at the facility.

Resident Care Coordinator stated that since they have worked at the facility the administrator was there five days a week although they were out for a short period of time due to illness.

It was determined that the previous administrator was available to residents to voice their concerns. The facility now has a new administrator. This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250516160354

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: 08/25/2025

NARRATIVE

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Resident is not being properly supervised causing other residents to feel unsafe.- UNSUBSTANTIATED

It was reported that residents were told Resident 1 (R1) would be moving out and are upset R1 is still living at the facility.

LPA reviewed staff schedule for May 2025. The staff schedule shows in the assisted living section of the facility there were 1 Med Tech, 2 care givers and 1 floater staff on duty for the AM and PM shifts. The memory care section had 1 Med Tech and 2 care staff for the same shifts.

Resident Care Coordinator stated that Resident 1 no longer lives at the facility.

It was determined that the facility has adequate staffing to supervise residents, the resident in question has since moved out of the facility. This allegation is unsubstantiated.

Although the above 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 facility RCC Carrie Breaux.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC9099 (FAS) - (06/04)

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