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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604329
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:43:53 PM

Document Has Been Signed on 09/26/2023 01:43 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:RUSSELL HOME LAKESIDEFACILITY NUMBER:
374604329
ADMINISTRATOR:TAITI, TAGIILIMAFACILITY TYPE:
735
ADDRESS:8672 GOLDEN RIDGE RDTELEPHONE:
(619) 749-9528
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 4CENSUS: 4DATE:
09/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:DSP Monique Lewis & Co-Administrator Krista DuvallTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit DSP Monique Lewis. LPA then met with Co-Administrator Krista Duvall, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/21/2023). The LIC624 described a medication incident involving Client #1 (C1). [See LIC 811 Confidential Names List for a description of C1.]

During today’s visit, LPA performed a brief facility tour and welfare check on clients in care, finding no safety concerns. LPA also reviewed pertinent records and interviewed relevant staff.

No deficiencies were observed or cited during today's visit. However, LPA issued Technical Assistance (TA) regarding medication administration processes and regarding reporting requirements.

An exit interview was conducted with Duvall, to whom a copy of this report, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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