185002877-9-4-2024-59-AS-KHOS-D92N3S-20240912100650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 185002877
Report Date: 09/04/2024
Date Signed: 09/04/2024 01:53:06 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
06/06/2024 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 59-AS-20240606130507

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
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Prospective Administrator, Anthony Faulkner		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff does not provide a safe environment for resident.
Staff does not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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On September 4, 2024 at approximately 01:00 PM Licensing Program Analyst (LPA), Farhaan Sarangi made an unannounced visit to Eagle Lake Village and met with Prospective Administrator, Anthony Faulkner. The purpose of this visit was to deliver the results of a complaint investigation conducted by LPA Jaynae Boyles.

LPA Jaynae Boyles investigated, “Staff does not provide a safe environment for residents”. LPA Boyles interviewed the administrator, and it was discovered that there was conflict between one resident and a married couple who had recently moved into the facility due to a disagreement with the courtyard and the plants. Furthermore, the administrator rectified the conflict by offering the married couple a new room on the other side of the facility to prevent any further conflict from occurring. The married couple explained to the LPA that they were never unkind, disrespectful or unsafe to any residents within the facility.

(Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240606130507

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: 09/04/2024

NARRATIVE

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LPA Boyles investigated, “Staff does not treat resident with dignity and respect”. LPA did not have corroborating evidence to support this allegation. Furthermore, the facility does not have video camera evidence. The LPA was unable to interview the staff involved as they are on medical leave with no projected return date.

Although the 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 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

LIC9099 (FAS) - (06/04)

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