185002877-9-4-2024-59-AS-FSAI-D8SSJ2-20240904135426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 185002877
Report Date: 09/04/2024
Date Signed: 09/04/2024 01:54:32 PM

Document Has Been Signed on 09/04/2024 01:54 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 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: 60	DATE:	09/04/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Prospective Administrator, Anthony Faulkner		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On September 4, 2024 at approximately 1:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi conducted a Case Management-Incident Inspection at Eagle Lake Village. LPA met with Prospective Administrator, Anthony Faulkner. During the Case Management-Incident Inspection, LPA reviewed incident reports from July 23, 2024 through July 29, 2024, and identified residents that had fallen. LPA reviewed the Fall Reduction Program Plan for the facility. Resident #1 is currently on a Fall Prevention Plan to mitigate the falls and that appropriate measures are taken to ensure that falls are happening less frequently. During the most recent fall, resident did not sustain any significant injuries. Resident #2 is not a Fall Prevention Plan. The incident that was reported to CCL was an isolated incident regarding the resident falling. Prospective Administrator reported no significant injuries to the resident. Prospective Administrator reported that there is additional observations that are being conducted to ensure that the resident does not have additional falls in the facility. In addition, facility is also encouraging visits with the Primary Care Physician. Resident #3 was attempting to retrieve the walker and fell. Resident #3 sustained a fracture and is currently in a Skilled Nursing Facility. Responsible Parties are currently in communication with the facility. During the incident in question, Resident was sitting on the couch with other residents and then all of a sudden just got up and grabbed the walker. While grabbing the walker, the resident fell when staff members were occupied with other residents. Furthermore, Resident did not seek assistance from staff before the fall. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/04/2024

NARRATIVE

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Resident #4 had an unwitnessed fall and that staff found the resident on the floor. Resident sustained a fracture and is currently returning back from the Skilled Nursing Facility sometime this week. LPA inquired about the contingency plan to ensure safety for the resident. Prospective Administrator reported to the LPA that they are going to reassess the resident, put the resident on alert charting and put the resident on a fall risk plan. Service Plan will be updated accordingly.

LPA requested the following document to be sent to the Regional Office via email:

-Fall Prevention Plan

No deficiencies were cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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