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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604329
Report Date: 05/15/2024
Date Signed: 05/16/2024 02:16:06 PM

Document Has Been Signed on 05/16/2024 02:16 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:RUSSELL HOME LAKESIDEFACILITY NUMBER:
374604329
ADMINISTRATOR/
DIRECTOR:		TAITI, TAGIILIMAFACILITY TYPE:
735
ADDRESS:8672 GOLDEN RIDGE RDTELEPHONE:
(619) 749-9528
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 4CENSUS: 3DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Nicole GonzalesTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Debbie Correia, made an unannounced visit to conduct the required One-Year Inspection. LPA Correia was greeted by Administrator Gonzales, introduced herself and explained the purpose of the visit. The facility is licensed to serve four (4) clients aged 18 to 59.. There was one staff member present and no clients present during today's inspection.

LPA Correia conducted resident records reviews for a current Physician's Report, Resident Appraisal, Needs & Services Plan/ IPP, Identification and Emergency Information, and Admission Agreement, and personnel records were reviewed for First Aid/CPR certification, Criminal Record Clearance, TB clearance, and Health Screening Report, and required training. The facility was equipped with operable carbon monoxide and smoke alarms. The facilities last disaster drill was conducted on February 3, 2024.

LPA Correia, accompanied by Administrator Gonzales, conducted a facility tour, and inspected resident rooms. The facility was sanitary and in good repair. Pathways were free of obstruction and slip hazards. Required postings were observed. Resident bedrooms contained the required furnishings. Bathrooms used by clients were in operable order. Doors, windows and screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: RUSSELL HOME LAKESIDE
FACILITY NUMBER: 374604329
VISIT DATE: 05/15/2024
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The facility was equipped with emergency lighting, and first-aid kit and manual. Medications were housed in a locked cabinet. Cleaning supplies and other toxins were inaccessible to clients in care. There was a pool on the property that is equipped with a five foot locked fence that is inaccessible to clients in care. The facility had ample space for activities and a large outdoor shaded area. Per Administrator Gonzales, there are no firearms or other weapons on the facility premises. The facility had a 7-day supply of non-perishable and a 2-day supply of perishable food. The facility’s ambient internal temperature was compliant at 74 degrees Fahrenheit. The facility's hot water temperature for faucets used by clients measured between 105.3 and 106.0 degrees Fahrenheit.


Based on today’s inspection, there are no deficiencies being cited. An exit interview was conducted Administrator Gonzales who's signature below acknowledges receipt of these documents.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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