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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604472
Report Date: 09/30/2022
Date Signed: 09/30/2022 10:49:39 PM


Document Has Been Signed on 09/30/2022 10:49 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
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: 12DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Licensee Kay CabucoTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an annual required licensing inspection. LPA Correia was greeted by Caregiver Erika Rico, identified herself, and met with Licensee Kay Cabuco to whom was explained the purpose of the visit.

During today's visit, LPA Correia, accompanied by Licensee Kay Cabuco, toured the facility and verified compliance with infection control practices. LPA Correia and Licensee Cabuco reviewed the facility’s Plan for Epidemic Outbreak Specific to the COVID-19 Mitigation Plan Report. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents, and visitors; sign-in policy enacted for all visitors. LPA Correia observed infection control signs posted at the facility entrance, as well as posted throughout the facility to promote infection control/universal precautions. Also observed were hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an ample supply of disinfectant products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with Licensee Cabuco, and a copy of this report, along with the Licensee Rights (LIC 9058) will be sent by Licensee Cabuco. Signature on this form confirms receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
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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