374604472-7-5-2024-08-AS-JLOT-D83PHL-20240812112006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604472
Report Date: 07/03/2024
Date Signed: 07/05/2024 11:23:22 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2024 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20240429134128

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:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Administrator Herika Rico		TIME COMPLETED:	02:31 PM

ALLEGATION(S):

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Facility did not issue required refund to resident's authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings for the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Herika Rico.

It was alleged that the Licensee did not provide Resident 1’s (R1’s) Responsible Party (RP) a full refund after discharge from the facility. A records review revealed R1 was admitted to the facility on February 2, 2022, subsequently R1 was voluntarily discharged on February 9, 2022, with no prior notice. Interviews conducted with Outside Source 1 (OS1), Staff 1 (S1) and a facility records review revealed the facility issued the RP a refund in an amount meeting the Department’s mandate.

An interview conducted with OS1, and a prior complaint filed against the facility, alleged the Admission Agreement did not meet California Code of Regulations, Title 22, Division 6, Chapter 8, therefore there was no contractual agreement in place and Title 22 refund mandate was not warranted.

[CONTINUED ON LIC 9099C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240429134128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LAKESIDE MANOR	FACILITY NUMBER: 374604472
	VISIT DATE: 07/03/2024

NARRATIVE

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The Department’s investigation regarding the allegation that the Admission Agreement did not meet State mandate was determined to be unsubstantiated declaring R1’s Responsible Party (RP) was bound by the terms as defined with-in the agreement. [See LIC 811 for Confidential Names]

Based on the Department's investigation there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Rico to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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