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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604472
Report Date: 06/21/2024
Date Signed: 06/21/2024 05:14:16 PM


Document Has Been Signed on 06/21/2024 05:14 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:LAKESIDE MANORFACILITY NUMBER:
374604472
ADMINISTRATOR:CABUCO, KAYFACILITY TYPE:
740
ADDRESS:9308 EMERALD GROVE AVETELEPHONE:
(619) 564-9660
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY:15CENSUS: 14DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Resident Service Coordinator (RSC) Herika Rico
TIME COMPLETED:
04:15 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 Herika Rico, identified herself and explained the purpose of the visit. The facility is licensed to serve 15 residents age 60 and above, 90 of whom may be non-ambulatory, 20 bedridden, and 20 residents who may be on hospice care.

Resident records were reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, and Admission Agreement. The facility carbon monoxide and smoke alarms were last inspected on February 20, 2024. The facilities last disaster drill was conducted on April 1, 2024.

During today’s visit, LPA Correia conducted a partial interior tour of the facility, resident and facility records reviews. An overall inspection of the facility began today, however, due to time constraints LPA was unable to complete the visit and will return at later time to conduct the remaining portion of this inspection.

Based on today’s inspection, there are no deficiencies being cited. An exit interview was conducted and a copy of this report, and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) will be provided to Herika Rico whose signature on this form acknowledges receipt of these documents.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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