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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002877
Report Date: 08/12/2024
Date Signed: 08/12/2024 12:51:52 PM


Document Has Been Signed on 08/12/2024 12:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 56DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Regional Director, Jeffery Dillon
Prospective Administrator, Anthony Faulkner		TIME COMPLETED:
01:00 PM
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On August 12, 2024 at approximately 11:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Eagle Lake Village for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Regional Director, Jeffery Dillon and Prospective Administrator, Anthony Faulkner and was granted access into the facility.

LPA and Administrative Staff toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2024 at the time of the inspection. All smoke detectors sound directly to the fire station. Carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in facility bathroom measured at 106 degrees, within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of vacant bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility. Facilities Infection Control Plan is currently being updated (See LIC 9102-Technical Advisory). Emergency Disaster Plan is currently being updated(See LIC 9102-Technical Advisory). Annual Continuation will be conducted at a later date and time.
No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted, and a copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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