374604472-9-27-2021-08-AS-DCOA-C79NSU-20210927104342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604472
Report Date: 09/20/2021
Date Signed: 09/27/2021 10:45:06 AM

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:	LAKESIDE MANOR		FACILITY NUMBER:	374604472
ADMINISTRATOR:	CABUCO, KAY		FACILITY TYPE:	740
ADDRESS:	9308 EMERALD GROVE AVE		TELEPHONE:	(619) 564-9660
CITY:	LAKESIDE	STATE: CA	ZIP CODE:	92040
CAPACITY:	15	CENSUS: 13	DATE:	09/20/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Applicant Kay Cabuco and Administrator Anna Kearns		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Debbie Correia, conducted an announced Pre-licensing and Component IIl visit at a Residential Care Facility for the Elderly (RCFE) to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. LPA Correia identified herself to Applicant Kay Cabuco and Administrator Anna Kearns and explained the purpose of the visit. The application is to serve fifteen (15) residents ages 60 and above, all (15) of whom must be non-ambulatory and/or receiving Hospice Care. The facility can also serve five (5) bedridden residents. The Lakeside Fire Protection District granted Fire Clearance on July 21, 2021. During today's visit LPA Correia, accompanied by Applicant Cabuco and Administrator Kearns conducted a tour of the facility. According to Applicant Cabuco, there will be no firearms or ammunition stored on site. No pools or bodies of water were observed. Indoor and outdoor passageways are free from obstructions. All window screens are clean and in good repair. All facility hallways are well-lit. fire, smoke alarms, and carbon monoxide detectors were all observed and operational. There is a bed for each resident's bedroom, equipped with padded covered mattresses, and pillows, observed clean and in good repair. There is sufficient closet and drawer space for resident belongings. Each resident bedroom is furnished with a chair, lamp, and a night stand. Resident bathrooms are also in good repair, equipped with handrails, and non-skid mats. The facility maintains a sufficient supply of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, hand towels, and washcloths. LPA Correia observed a seven-day supply of non-perishable and a 3 day supply of perishable food. A sample of the facility meal menu was present. The facility kitchen also maintains sufficient amounts of clean utensils, and equipment for proper storage of food items, and locked storage for sharp items (i.e. knives). LPA Correia observed an office for administrative staff that has a confidential storage area for personnel and resident records. LPA observed a locked storage cabinet for residents' medications. Emergency exit plans, facility policy, and residents' personal rights are posted in prominent areas. There is a shaded outdoor activity space, and a common room available for visitors.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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: LAKESIDE MANOR	FACILITY NUMBER: 374604472
	VISIT DATE: 09/20/2021

NARRATIVE

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LPA observed a first aid manual and kit maintained at the facility. The facility area to store cleaning supplies and other toxic chemicals. There is an operating telephone land line. There is emergency lighting and supplies readily available for safety measures. The hot water temperature used by residents in care measured between 116 and 118 degrees F, and the central air unit measured 76 degrees.

Component III was completed with the facility applicant and Administrator. LPA Correia reviewed continuing operational requirements, as well as record keeping and physical plant compliance. The applicant shall contact the Centralized Application Bureau (CAB) for completion of this pending facility application. Based on today's evaluation, the facility is in compliance with CCR, T22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing inspection is complete and the facility has no deficiencies.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Administrator's e-mail address. An electronic mail read receipt confirms delivery of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC809 (FAS) - (06/04)

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