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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602824
Report Date: 10/29/2021
Date Signed: 11/01/2021 03:43:44 AM

Document Has Been Signed on 11/01/2021 03:43 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CPSRC BMDTP-LAKESIDEFACILITY NUMBER:
374602824
ADMINISTRATOR:NANCY ELDRIDGEFACILITY TYPE:
775
ADDRESS:11757 TOPO LANETELEPHONE:
(619) 561-7405
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 30CENSUS: 30DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Nancy EldridgeTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual inspection on October 29, 2021. LPA met Administrator Eldridge, identified herself and explained the purpose of the visit.

LPA, accompanied by Administrator Eldridge conducted an overall tour of the facility, and observed and spoke with clients in care. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements that are most relevant to protecting the health of clients in care and staff, including in the area of infection control practices.

LPA reviewed current Community Care Licensing (CCL) guidance to incorporate in the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Administrator Eldridge including but not limited to the following sections: staff vaccination requirements and staff and consumer vaccination tracking, and visitation guidelines. LPA reviewed 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 observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy; signs posted at facility entrance with the facility’s visitor policy and signs 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; a designated visitation area if necessary; emergency agencies’ contact information posted in a location visible to staff and clients; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CPSRC BMDTP-LAKESIDE
FACILITY NUMBER: 374602824
VISIT DATE: 10/29/2021
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No deficiencies were observed during today's visit. An exit interview was conducted with Administrator Eldridge and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) will be provided via email to Administrator Eldridge 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: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
LIC809 (FAS) - (06/04)
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