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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600742
Report Date: 01/31/2022
Date Signed: 01/31/2022 08:22:15 PM

Document Has Been Signed on 01/31/2022 08:22 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:DSC-LAKESIDE HOUSEFACILITY NUMBER:
374600742
ADMINISTRATOR:PATRICIA BARBERFACILITY TYPE:
735
ADDRESS:9275 WESTHILL ROADTELEPHONE:
6194607333
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 6DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Direct Support Professional (DSP) Nancy SpencerTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced required annual inspection. LPA met with Direct Support Professional (DSP) Nancy Spencer, identified herself and explained the purpose of the visit. LPA Correia also identified herself and explained the purpose of the visit to Administrator Diane Spurgeon when she arrived at the a facility short while later.

The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. The facility has Plans for Infection Control, and will implement Physical Distancing as needed. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, ability to quarantine or isolate if necessary and essential health and safety. LPA will also review the facility's LIC 808 COVID-19 mitigation plan to ensure it is updated with current guidance.

LPA entered through one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy enacted for all visitors; signs posted throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and as much as possible, residents; hand sanitizer/hand washing stations readily available; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE.

No deficiencies were observed during today's visit. An exit interview was conducted with DSP Spencer and Administrator Spurgeon and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) will also be provided via email to the DSP and Administrator at the conclusion of the visit. An electronic reply response confirms receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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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