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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604472
Report Date: 07/03/2024
Date Signed: 07/04/2024 06:37:38 PM


Document Has Been Signed on 07/04/2024 06:37 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: 13DATE:
07/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator Herika RicoTIME COMPLETED:
03:15 PM
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LPA Correia conducted an unannounced visit to obtain signatures on an amended report. LPA identified herself to Administrator Rico, was granted entry into the facility, and explained the purpose of the visit.

During today's visit LPA Correia obtained signatures on an amended report.

An exit interview was conducted with Administrator Rico whom a copy of this report and the Licensee's Rights (LIC9058 01/16) was provided via electronic mail. LPA requested an email response as confirmation of receipt of the document.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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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