374604472-1-31-2024-08-AS-SJAB-D2P2Q9-20240221163533

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604472
Report Date: 01/29/2024
Date Signed: 01/31/2024 08:34:26 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
01/08/2024 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20240108103817

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: 14	DATE:	01/29/2024
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Owner Matthew DelBruegge		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Neglect resulted in pressure injury
Neglect resulted in malnourishment

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings for the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Owner Matthew DelBruegge.

On January 8, 2024, Community Care Licensing (CCL) received a complaint alleging neglect of Resident 1 (R1) resulted in pressure injury and neglect of R1 resulted in malnourishment. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to R1’s Physician Report, dated January 17, 2023, R1 has a mild cognitive impairment, is non-ambulatory, is on a special diet due to dialysis, can follow instruction and can communicate needs.

According to allegation, on January 3, 2024, R1 was observed to have pressure injuries on the elbow and sacral area in which staging had not been determined but were alleged to have occurred as a result of neglect.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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-20240108103817

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: 01/29/2024

NARRATIVE

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Based on records reviewed, R1 moved into facility on December 6, 2023. Records showed, R1 was receiving wound care from Home Health Provider for elbow and sacral wound since October 2023. According to records, sacral wound being treated was as a Stage 2 pressure ulcer. Interview with Home Health provider confirmed R1 was receiving twice weekly visits from home health. Records reviewed also revealed that R1 was transferred to Hospice care as of December 26, 2023, due to requiring a higher level of care. Interview with caregivers revealed that R1 was rotated every two hours and changed as necessary. Interview with Hospice Agency revealed there were no concerns with the level of care provided to residents at the facility. Interview with Hospice also confirmed Hospice agency is now providing care to pressure injury. Interview with outside source revealed that there was no suspected neglect to R1.

It was also alleged that facility neglect resulted in R1 being malnourished. Records reviewed revealed R1 could feed self. Interviews with staff revealed R1 only eats about half of their servings. Records reviewed revealed R1’s has declined cognitively since September of 2023 and has increased lethargy. Records also revealed R1’s appetite ranges from Good to Fair, week by week. Lastly, records reviewed revealed R1’s Body Mass Index is 19.1. According to the Center’s for Disease Control and Prevention (CDC) 19.1 is considered healthy weight.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Owner Matthew DelBruegge to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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