374604472-12-12-2023-08-AS-IESA-CZ4P6U-20240102100254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604472
Report Date: 12/12/2023
Date Signed: 12/12/2023 07:03:56 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/02/2023 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20231002121928

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:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	Caregiver Litzy Serrano		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Licensee did not provide accorded refund.
Licensee did not ensure removal of oxygen tanks from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings on a complaint investigation regarding the above-mentioned allegations. LPA Correia was greeted by Caregiver Litzy Serrano and explained the purpose of the visit.

The Department's investigation included staff and outside source interviews, as well as facility, resident, and outside source records reviews.

It was alleged the Licensee did not provide Resident 1 (R1) (see LIC 811 Confidential Names List for identification) their accorded refund upon discharge from the facility. An Outside Source 1 (OS1) interview and 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 and a facility and resident records review revealed the Licensee required a 30-day written notice to be eligible for a refund of unused rent money received post the 30-day date provided on the notice of relocation minus any additional days a resident or a resident’s belongings remained at the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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-20231002121928

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LAKESIDE MANOR	FACILITY NUMBER: 374604472
	VISIT DATE: 12/12/2023

NARRATIVE

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Per Title 22 regulation, the Licensee was mandated to provide a refund of 80 percent of the Preadmission fee paid over $500. Outside source and staff interviews, as well as a facility and outside source records review, revealed the Licensee provided a refund, on R1's behalf, of an amount that exceeded the facility’s protocol and Title 22 mandate.

It was also alleged the Licensee did not ensure removal of R1’s oxygen tanks from the facility. An interview with Outside Source 1 (OS1) revealed when R1 was discharged from the facility the Licensee did not provide three (3) of R1’s oxygen tanks with the transport agency. An interview with facility Staff 1 (S1) revealed that R1 received oxygen tanks by an Outside Agency 1 (OSA1) at the time R1 was admitted to the facility. The interview also revealed an oxygen tank provided by OSA1 was given to R1’s transport agency at discharge, and any other of OSA1’s property provided to the facility for R1’s care was retrieved by OSA1. An interview with an additional agency affiliated with OSA1 corroborated the deliverance of oxygen tanks to the facility the day of R1’s admission and upon retrieval after R1’s discharge, R1 had left the facility with an oxygen tank during transport. The interview with S1 also revealed the three (3) oxygen tanks in question were empty when they were brought to the facility with R1 upon arrival from out of state via ambulance transport. An interview with an additional Outside Source 2 (OS2) revealed they believed the oxygen tanks belonged to an Outside Agency 2 (OSA2) located out of State. OS2 also revealed they coordinated to have the tanks picked up from the facility on February 19, 2022, by a friend. An interview with OSA2 revealed they did not prescribe or provide R1 with Oxygen tanks. Additional records reviews revealed the Licensee had reached out to OS2 to facilitate the removal of R1’s three (3) oxygen tanks left behind.

Based on the Department’s investigation the above-mentioned allegations were of the complaint were determined to be unfounded. An unfounded finding means that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the Department has dismissed the complaint allegations.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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