Eagle Lake Village

Type of visit: Case Management - Other

On 07/16/2026 licensing program analyst (LPA) Marisa Chiarelli came announced to the facility and met with resident care coordinator Zjanett Manning. LPA Chiarelli arrived at the facility to collect documents that are for a complaint investigation 59-AS-20260708094424. Several topics were discussed No deficiencies are being cited on todays visit. Exit interview conducted and copy of report left with facility.the state’s words, verbatim · CDSS document, Jul 16, 2026

Type of visit: Required - 1 Year

On 07/15/2026, Licensing program analyst (LPA) Marisa Chiarelli arrived to the facility unannounced to conduct a one year required inspection. LPA Chiarelli met with Zjannet Manning resident care coordinator and explained the purpose of the visit. LPA Chiarelli and RCC Manning toured the facility together to ensure the health and safety of residents in care. Areas toured included but not limited to, residents bedrooms, bathrooms, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medication is kept in a locked room. The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke and carbon monoxide detectors are all in working order. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. No firearms are on premises. Two deficiencies are being cited on today's inspection, exit interview conducted and copy of report left with the facility.the state’s words, verbatim · CDSS document, Jul 15, 2026

Allegation investigated: Staff does not assist resident with management of their oxygen administration. - UNSUBSTANTIATED Resident fell and was not provided assistance for several hours. - UNSUBSTANTIATED

/30/2026 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with Executive Director Brian Moore and explained the purpose of the visit. During the course of the investigation LPA conducted interviews and reviewed documents. Continued on LIC9099-C Unsubstantiated Staff does not assist resident with management of their oxygen administration. – UNSUBSTANTIATED It was reported that when Resident 1 (R1) first moved into the facility, an RN assisted them with oxygen use and supplies, now staff told R1 they are not allowed to help with oxygen. LPA reviewed an invoice from an oxygen supply company dated 11/12/2025 which states R1 received a supply of oxygen equipment (concentrator and other supplies). LIC602 Physicians Reports dated 02/16/2022 and 02/17/2026 state that R1 is able to administer their own oxygen. Care Plan dated 08/25/2025 states that R1 requires assistance with regular breathing treatments and R1 is independent with their oxygen. Admission Agreement for R1 dated 12/10/2022 states that the facility does not provide higher levels of care such as nursing. Resident 1 stated they can manage their oxygen but if the breathing tubes are not on properly or it falls on the floor they may not be able to grab them. Administrator stated that R1 manages their own oxygen and staff do not assist R1 with their oxygen. It was determined that R1 can manage their own oxygen but would benefit from more frequent checks by care staff to ensure that their oxygen lines have not fallen off or become stuck in the wheelchair. This allegation is unsubstantiated. Continued on LIC9099-C Resident fell and was not provided assistance for several hours. – UNSUBSTANTIATED It was reported that Resident 1 (R1) fell and remained on the floor for several hours, calling for help from approximately 1:30 a.m. to 5:00 a.m on 12/17/2025. LPA observed R1’s room to be very cluttered with minimal clearance for ambulation. LPA reviewed an incident report that was submitted on 12/18/2025 which reports on 12/17/2025 at 4:00 AM R1 was found on the floor of their apartment. R1’s pendant was on the floor under their wheelchair. R1 was not wearing their oxygen when discovered. R1 was transported via EMS to the hospital and admitted for treatment. LPA reviewed R1's pendant response times which show on 12/16/2025 10:30 PM R1 pressed their pendant. R1 did not press their pendant again on 12/16/2025 or 12/17/2025. Resident 1 stated they fell and pressed their button at 1:00 am and no one came in until the shift change. R1 stated they called out for hours. Administrator stated On 12/17/2025 around 4:00 am one of the care staff went to R1’s room to give them their medication and they found R1 on the floor. States the 4:00 AM medication dispensing is at R1's request. States that depending on R1's current needs their checks are increased, staff would not check on a resident unless their pendant has been pressed. Before R1 fell they were not yet on alert charting which increases their checks but they are now on frequent checks. It was determined that on 12/17/2025 R1 did fall and was found by staff at 4:00 AM. R1 was not on alert charting prior to the date of the fall on 12/17/2025. Per documentation R1 did not press their pendant to alert staff after 10:30 PMon 12/16/2025 or in the early morning hours of 12/17/2025. This allegation is unsubstantiated. Based on interviews and evidence obtained during the investigation, the preponderance of the evidence has not been met; therefore, the allegations are unsubstantiated. 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 No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was provided to Executive Director Brian Moore.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 59-AS-20260421144053

Type of visit: Case Management - Other

04/30/2026 10:15 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a case management visit. LPA met with Executive Director Brian Moore and explained the purpose of the visit. On 04/29/2026 while conducting a complaint investigation LPA observed Resident 1's (R1) room to be very cluttered with minimal clearance for ambulation. LPA observed R1’s bed to be covered with various items which would make it impossible for R1 to sleep in their bed. R1 states they chose to not sleep in their bed as they have a difficult time transferring and prefer to sleep in their recliner. LPA observed a recliner in R1’s room. The facility does not currently have a waiver in place that would allow R1 to sleep in their recliner in lieu of their bed. LPA advised the administrator that the facility is required to immediately request a waiver for R1 to sleep in their recliner in lieu of their bed. Facility administrator was advised to submit the following to obtain a waiver for Resident 1 (R1) to sleep in a recliner in lieu of their bed: Written and signed request from the resident. Written and signed permission / recommendation from the resident's physician. Written and signed permission from the resident's responsible party (if any). Written and signed request from the facility with all of the above shall be submitted to licensing for review / approval. No deficiencies were cited. Technical assistance was provided. An exit interview was conducted and a copy of the report was provided to administrator Brian Moore.the state’s words, verbatim · CDSS document, Apr 30, 2026

Allegation investigated: Staff neglect resulted in resident sustaining multiple pressure injuries. - UNSUBSTANTIATED Staff did not seek timely medical attention for resident. - UNSUBSTANTIATED Staff did not inform residents’ representative of a change in residents’ condition. - UNSUBSTANTIATED

/29/2026 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with Executive Director Brian Moore and explained the purpose of the visit. During the course of the investigation multiple interviews were conducted and documents were reviewed. Continued on LIC9099-C Unsubstantiated Staff neglect resulted in resident sustaining multiple pressure injuries. - UNSUBSTANTIATED Based on R1’s care plan and care needs, R1 was independent in their care. R1 needed standby assistance in the shower. R1 was able to conduct all other aspects of their care on their own. On 8/20/2025, staff were cleaning R1 after R1 had a toileting accident and noted R1 had black tar like stool and blood on their rectum, it was also noted R1 had a black toe on their right foot. Staff were not aware of the black toe prior to this. Per R1’s care plan staff had no expectation to perform body checks on R1. Staff would not have seen the toe as R1 showers and dresses themselves. R1 is also able to communicate their needs and voice if R1 is in pain. R1 voiced no concerns nor complaints of pain. On 8/20/2025, R1 was admitted to Renown Regional Hospital on 8/20/2025 due to “Acute osteomyelitis of toe of right foot.” R1 was also admitted due for gastrointestinal bleeding. R1 received wound care treatment due to “noted bone exposure.” On 8/22/2025, “Patient was taken to the OR by orthopedics on 8/22, underwent disarticulation of a necrotic second toe.” It was also discovered R1 had pressure wounds to their “Pretibial Proximal Left” (Amputated leg), and “Right Lateral Hallux” (amputated toe). R1 also had “Buttocks incontinence dermatitis” (showed a red and inflamed area around their buttocks which turned white). R1 was discharged on 8/26/2025 to Lassen Nursing and rehab. Based on R1’s care plan and their independence in care, the staff had no reasonable expectation to perform body checks on R1. R1 voiced no concerns nor voiced they were in pain. The preponderance of the evidence has not been met; therefore, the allegation is unsubstantiated. Continued on LIC9099-C Staff did not seek timely medical attention for resident. - UNSUBSTANTIATED On 8/20/2025, while conducting morning incontinence care, staff noted R1 had a black tar like stool and blood on their rectum. It was also noted R1 had a black toe on their right foot. After both of these concerns were found, staff immediately called 911 and R1 was sent to the hospital. Prior to the discovery of the two concerns, there was no indication R1 needed any sort of medical intervention. R1 cares for their own activities of daily living (ADLs) and has standby assistance with showers. R1 can communicate any concerns or if they are in pain to staff and did not disclose any issues. Based on the totality of the evidence found, the preponderance of the evidence has not been met; therefore, the allegation is unsubstantiated. Staff did not inform residents’ representative of a change in resident's condition. - UNSUBSTANTIATED Prior to 08/20/2025 when staff called 911 and R1 was sent out to the hospital for blood in stool and a black right toe, staff were not aware of a change in condition for R1. Prior to the discovery of the two concerns, there was no indication that R1 needed any sort of medical intervention. R1 cared for their own ADLs and had standby assistance with showers. R1 is able to communicate any concerns or if they are in pain to staff and did not disclose any issues. Per R1’s care plan staff had no expectation to perform body checks on R1. LPA reviewed an incident report dated 08/20/2025 reporting that staff discovered R1 in bed incontinent of large black stool. Noted visible blood on rectum as well as a bloody back right toe - called 911 and resident was transported to hospital for evaluation. Incident report includes RP Krissy notified, PCP notified. Emergency Contact RP Notified via voice mail - return call with Krissy. LPA searched database for other incident reports for R1 and none were reported. Based on the totality of the evidence found, the preponderance of the evidence has not been met; therefore, the allegation is unsubstantiated. 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. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was provided to Executive Director Brian Moore.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 59-AS-20250821162815

Type of visit: Required - 1 Year

08/26/2025 09:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Resident Care Coordinator (RCC) Carrie Breaux and explained the purpose of the visit. LPA Knight and the RCC toured the facility together to ensure the health and safety of residents in care. Assisted Living and Memory Care units were inspected. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas, patio areas and dining room. Staff and resident files were reviewed. All employees requiring background checks are cleared. All required postings are displayed within facility. Medication is locked in the medication room. Medication was reviewed. Common area was clean and in good repair. All rooms that were inspected had required furniture, bedding, and lighting. Bathrooms were clean and in good repair with the the exception of one common area bathroom that was out of order, and two resident showers that were soiled. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Johnson Controls inspects and services the smoke detector and fire alarm system annually. Continued on LIC809-C Page 2 There are no pools/bodies of water on the premises. Last disaster drill was conducted in August 2025 which was a fire drill. The facility has been conducting fire drills every 3 months. Fire drills are conducted by shift. The following deficiencies were observed and are being being cited as a result of today’s inspection under Title 22. California Code of Regulations, (Title 22), is being cited on the attached LIC 809D. During file review LPA observed that 5 of 5 staff files did not have current first aid certificates. During the facility tour LPA observed the following physical plant deficiencies: common area restroom toilet not functioning, common area refrigerators in both the assisted living and memory care units have locks on the refrigerators, 1 of 8 resident rooms had a soiled shower curtain, 2 of 8 resident shower floors were soiled or stained, 1 of 8 resident rooms door handle is not operating properly, there is a soiled and broken recliner in memory care patio area that needs to be removed, siding on the west side of the memory care unit exterior is broken / worn and needs to be repaired and painted, exterior column in memory care patio area is worn / broken and needs to be repaired, replaced and painted, cyclone fence in front / east side of facility lot (surrounds ditch) has a broken section that needs to be repaired which poses a potential health, safety or personal rights risk to persons in care. An exit interview was conducted and copy of report was provided to Resident Care Coordinator Carrie Breaux.the state’s words, verbatim · CDSS document, Aug 26, 2025

Allegation investigated: 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

/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 Page 2 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 Page 3 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.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 59-AS-20250516160354

Allegation investigated: Staff are not following physicians’ instructions.- UNSUBSTANTIATED Staff did not ensure that resident is provided an adequate amount of water. - UNSUBSTANTIATED

/25/2025 03:30 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Shay Ewing. 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 to include Service Plan, Over the counter PRN and First Aid Orders, MAR, Physician’s Report, care notes, for 1 resident, staff list with telephone numbers, resident list. Continued on LIC9099-C Unsubstantiated Page 2 Staff are not following physicians’ instructions. - UNSUBSTANTIATED It was reported that resident's physician indicated that the facility needs to do a urine catch on Resident 1 (R1) to track how much R1 is urinating. LPA reviewed R1’s Service Plan dated 01/16/2025 indicates that R1 manages their own medication and independently coordinates their own healthcare appointments. Physicians report states that R1 is able to manage their own medication with assistance from family. LPA reviewed R1’s Over the counter PRN and First Aid Orders which includes Medication / Treatment: Urine collection/C+S if indicated. Instructions: UA and Culture to be collected as needed, for observed symptoms of a UTI. The facility does not have a physician’s order from R1’s doctor requesting the facility do a urine catch on R1 to track how much R1 is urinating. R1 stated that they are asked for a urine sample when they are at the hospital, and every time they take a blood test. Resident Care Coordinator stated that R1’s physician has not ordered a urine sample related to output but they do have a standing order in case or symptoms of UTI. It was determined that the facility does not have a physician’s order from R1’s doctor requesting the facility do a urine catch on R1 to track how much R1 is urinating. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Staff did not ensure that resident is provided an adequate amount of water. - UNSUBSTANTIATED It was reported that that per R1’s physician, staff need to encourage R1 to drink water every two hours. R1’s Service Plan dated 01/16/2025 indicates that R1 is independent with all activities of daily living and does not require assistance with meal reminders or feeding support. There is no physician’s order or notes on file at the facility requesting staff to encourage R1 to drink water every two hours. On 06/25/2025 LPA observed a hydration station in the common area / dining room that contained large containers of water and lemonade with ice. Resident interviews revealed that the facility has a hydration station and residents help themselves but staff do not offer water unless it is mealtime. Resident Care Coordinator stated that R1 is very capable of drinking water throughout the day. RCC stated the facility has hydration carts located in the front and back of the facility. RCC stated that staff offer residents something to drink 3 or 4 times a day in rounding. It was determined that R1 does not have a physician’s order or notes on file at the facility requesting staff to encourage R1 to drink water every two hours. This allegation is unsubstantiated. 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 provided to facility Executive Director Shay Ewing.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 59-AS-20250624144340

Allegation investigated: Facility staff did not dispense medications as prescribed Facility staff did not assist resident with medication refill

On February 19, 2025 at approximately 10:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Eagle Lake Village for the purpose of conducting a subsequent complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Anthony Faulkner, and was granted access into the facility. During the course of the investigation, LPA conducted interviews with staff, Resident #1 and a Witness. In addition, the LPA reviewed the Medication Administration Record for the date in question, reviewed the Care Notes from January 1, 2025 through February 17, 2025, and reviewed the Call Bell Log from January 20, 2025 through February 19, 2025. LPA toured the facility on February 10, 2025 and made observations. Complaint alleges that Facility staff did not dispense medications as prescribed. Based on interviews that were conducted and observations of facility documents and resident records, LPA could not prove or disprove the allegation occurred. (Report continued on LIC 9099C) Unsubstantiated Furthermore, LPA reviewed the Medication Administration Record (MAR) for the date in question and found no evidence of missed medications for the alleged date. LPA reviewed the Care Notes from January 1, 2025 through February 17, 2025, which also revealed no concerns. On one Care Note dated for January 30, 2025, the resident reported that the staff never responded to the residents room when pushing the call bell for medication. LPA reviewed the call bell log for the date in question and learned that the facility response time was eight (8) minutes. LPA conducted interviews and received inconsistent statements. LPA could not corroborate the allegation. Complaint alleges that Facility staff did not assist resident with medication refill. Based on interviews that were conducted with staff and an outside witness, LPA could not prove or disprove the allegation occurred. Furthermore, during interviews, LPA received inconsistent statements. LPA learned that the medication did run out and that the facility staff contacted the Nurse Practitioner for a refill which was refilled and picked up at the local pharmacy by the Residential Care Coordinator. LPA could not corroborate the allegation. A finding that the complaint allegations of Facility staff did not dispense medications as prescribed and Facility staff did not assist resident with medication refills are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 59-AS-20250205153700

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

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 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.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 59-AS-20240606130507

Type of visit: Case Management - Annual Continuation

On September 4, 2024 at approximately 11:00 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 Prospective Administrator, Anthony Faulkner, and was granted access into the facility. LPA and Prospective Administrator 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. Water temperature in facility measured at 106 degrees, within acceptable range of 105 to 120 degrees F. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Medication orders were reviewed. 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. First Aid kit was inspected and found to be appropriate during the inspection. LPA reviewed resident files and found that 2 out of 5 resident files did not have an updated LIC 602/Physician Assessment (See LIC 9102-Technical Violation). Prospective Administrator was under the impression that residents are supposed to be reappraised once every five years. LPA educated the Prospective Administrator and reviewed Regulation 87463(c)-Reappraisals. LPA reviewed staff files and found those to be appropriate. First Aid/CPR Card valid for staff that provide care and supervision to residents in care. LPA reviewed staff training and observed that 3 out of 5 staff members did not have the required training annually (See LIC 9102-Technical Violation). LPA educated the Administrator on the importance of every staff member shall have annual training as outlined in Title 22 regulation. (Report continued on LIC 809C) LPA requested the following documents to be sent: LIC 500- Personnel Report LIC 308- Designation of Facility Responsibility LIC 309- Administrative Organization Updated Infection Control Plan Most up-to-date Liability insurance Emergency Disaster Plan Control of Property Register of residents No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 4, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

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) 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.the state’s words, verbatim · CDSS document, Sep 4, 2024

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Aug 12, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Medication Management.

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 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.the state’s words, verbatim · CDSS document, May 10, 2024 · control 59-AS-20240508091401

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 13, 2024

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: Based on interviews and document review it was determined that R1 ran out of medications for at least a day.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: 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. 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.

Allegation investigated: Staff did not keep the facility free from pest. Resident sustained a pressure injury due to lack of care from staff. Staff do not meet resident's toileting needs. Staff do not meet resident's hygiene needs. Staff are using nicotine products in the presence of residents. Staff handled resident in a rough manner. Staff yelled at residents.

On 05/01/2024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with administrator. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation the administrator and four (4) staff were interviewed. LPA reviewed the following documents: pest control service records, home health records for residents who are receiving wound care services, staff meeting notes for the last six months. 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 provided to administrator. Unsubstantiated LPA investigated, “Staff did not keep the facility free from pest”. Three of the four staff interviewed reported that there were pests in the facility. Staff reported that there were mice in the facility, and it was reported to the administrator who resolved the matter with urgency. A review of the records of pest control services indicate that the facility regularly receives pest control services. The licensee has a pest control company on contract that comes once a month. The facility property is rural. When the weather changes the rodents seek shelter from the rain/snow. LPA did not observe any rodent droppings during the tour and the Administrator stated she and the licensee are aware there are rodents around due to the location of the property and that is the reason for the pest control contract. LPA investigated, “Resident sustained a pressure injury due to lack of care from staff”. According to the Administrator four residents receive wound care services from an outside agency. The administrator explained that the staff at the facility do not provide wound care for residents. Staff interviewed all reported that they do not provide wound care for residents. The staff and administrator reported to the LPA that if there is suspicion that a resident may have a pressure injury the resident is referred for wound care services immediately. LPA investigated, “Staff do not meet resident's toileting needs”. Based on observations and interviews, it has been concluded that facility has adequate staff for all toileting needs. Furthermore, staff is providing assistance to residents with their toileting needs per their care needs with no issues. LPA investigated, “Staff do not meet resident's hygiene needs”. Based on observations and interviews, it has been concluded that facility has adequate supplies for all hygiene supplies including soap, toilet paper and paper towels. Furthermore, staff is providing assistance to residents with their hygiene needs per their care needs with no issues. LPA investigated, “Staff are using nicotine products in the presence of residents”. The administrator and four staff interviewed reported that no staff member has been seen using a nicotine product in the facility. LPA investigated, “Staff handled resident in a rough manner”. The administrator and the staff have reported that no staff member has been observed to have been rough with a resident. The administrator reported that the facility has ongoing training to ensure that residents are handled with care when changing or transferring residents. LPA investigated, “Staff yelled at residents”. The administrator and four staff interviewed reported that no staff member has been seen yelling at residents.the state’s words, verbatim · CDSS document, May 1, 2024 · control 59-AS-20240305143731