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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600742
Report Date: 06/06/2024
Date Signed: 06/10/2024 09:15:14 AM

Document Has Been Signed on 06/10/2024 09:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:DSC-LAKESIDE HOUSEFACILITY NUMBER:
374600742
ADMINISTRATOR/
DIRECTOR:		MELISSA STEFFENHAGENFACILITY TYPE:
735
ADDRESS:9275 WESTHILL ROADTELEPHONE:
(619) 460-7333
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 4DATE:
06/06/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:49 PM
MET WITH:Direct Support Professional (DSP) Skye HamptonTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Correia conducted an announced Case Management visit due to an incident report Community Care Licensing received on June 06, 2024. LPA Correia introduced and identified herself to DSP Skye Hampton and explained the purpose of the visit.

During today's visit, LPA observed clients in care and conducted a staff interview.

The visit was in response to a self-reported client AWOL which occurred on June 6, 2024, at approximately 3:00 AM. An interview conducted with facility staff confirmed the details of the incident listed in the LIC 624. Based on LPA’s review of facility records and interview with staff it was determined that staff did not comply with the requirements of their facility Absentee Notification Plan. Deficiency is cited per California Health and Safety Code on the attached 809D form.

An exit interview was conducted with DSP Hampton. A copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) will be provided to Licensee at the conclusion of the visit.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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Document Has Been Signed on 06/10/2024 09:15 AM - It Cannot Be Edited


Created By: Debbie Correia On 06/06/2024 at 07:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DSC-LAKESIDE HOUSE
FACILITY NUMBER: 374600742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2024
Section Cited
HSC
1507.15

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Every community care facility that provides adult residential care ...shall, for the purpose of addressing issues that arise when an adult resident ... missing from the facility, develop and comply with an absentee notification plan for each resident or participant. The plan shall be part of the written Needs and Services Plan. The plan shall include participant’s authorized representative ... shall notify local law enforcement when a resident or participant is missing from the facility.

This requirement was not met as evidenced by.

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The Licensee agreed to seek CCL approved training regarding procedures and protocols during a client elopement.

The Licensee will provide proof of training by the POC due date.

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Based on interviews and record reviews facility staff did not follow the facility's Absentee Notification Plan by immediately contacting law enforcement when C1 eloped from the facility's temporary relocation.


This posed an immediate risk to 1 out of 4 clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jennifer Lott
LICENSING EVALUATOR NAME:Debbie Correia
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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