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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604472
Report Date: 11/18/2021
Date Signed: 11/23/2021 09:58:08 PM

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 MANORFACILITY NUMBER:
374604472
ADMINISTRATOR:CABUCO, KAYFACILITY TYPE:
740
ADDRESS:9308 EMERALD GROVE AVETELEPHONE:
(619) 564-9660
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY:15CENSUS: 13DATE:
11/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Licensee Kay CabucoTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced Case Management visit. LPA was greeted at the front door by Licensee Cabuco and was granted entry into the facility after identifying herself and disclosing the purpose of her visit.

During today’s visit, LPA conducted a tour of the facility, obtained copies of resident records, and conducted staff interviews.

The visit was initiated due to a self reported AWOL involving client #1, that occurred on November 16, 2021. The incident was submitted via form LIC 624 – Unusual Incident/Injury Report to Community Care Licensing (CCL), which was received in our office on November 17, 2021. Further Investigation is needed before determining findings.

This report was discussed with Licensee Cabuco. A copy of this report, and Licensee Rights (LIC 9058 01/16) was provided to Licensee Cabuco via email. LPA requested an email read reply response to confirms receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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