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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604472
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:43:55 PM

Substantiated


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
09/25/2023 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20230925150942
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: 15DATE:
03/20/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Karina Ramirez, StaffTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff did not ensure that resident was properly clothed.

Staff did not provide activities for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with Karina Ramirez, to whom she disclosed the reason for the visit.

Community Care Licensing (CCL) has investigated the above-listed complaint allegations. The investigation consisted of tours of the facility and interviews of facility staff and outside sources.

It was reported that Resident 1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] was observed seated in the living area of the facility with a top and a diaper on, but no bottom item of clothing. Interviews conducted during the investigation confirmed that, on occasions, staff would seat R1 in his/her wheelchair in the common area of the home with a top item of clothing and an adult brief with no bottom clothing or covering on.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 08-AS-20230925150942
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: 03/20/2024
NARRATIVE
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It was also alleged that facility staff did not provide activities for residents. It was reported that when the facility initially opened, licensees were good at providing activities and engaging the residents in activities. After a while, reportedly, licensees took a step back from the facility’s day to day operations; during that time period, activities ceased. Interviews conducted revealed that bingo is conducted periodically, but there is no set schedule, and the occurrences are random. Other than the occasional bingo games, interviews yielded that there are no activities provided for residents to participate in.

Accordingly, the above identified allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted with Karina Ramirez, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit. Karina’s signature below serves as acknowledgment of receipt of copies of the report and rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
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
09/25/2023 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20230925150942

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: 15DATE:
03/20/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Karina Ramirez, StaffTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Neglect resulted in questionable death.

Neglect resulted in resident not receiving timely medical attention.

Staff did not maintain a facility free of pests.

Staff did not maintain a clean facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with Karina Ramirez, to whom she disclosed the reason for the visit.

Community Care Licensing (CCL) has investigated the above-listed complaint allegations. The investigation consisted of tours of the facility, review of facility records, review of outside source records, and interviews of residents, staff, and outside sources.

It was reported to Community Care Licensing that neglect by the Licensee resulted in Resident 1 (R1) not receiving timely medical attention which contributed to R1’s death.

R1, who had a diagnosis of dementia, moved into the facility on1/3/2022. At that time, R1 was under the care of hospice due to cognitive and overall health decline. During R1’s stay in the facility, hospice services
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 08-AS-20230925150942
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: 03/20/2024
NARRATIVE
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[2] were initiated and discontinued on a few occasions. The investigation yielded that on 8/7/2023, R1 became agitated at the facility and began kicking and punching his/her bedroom windows. Staff attempted to redirect R1 and administered an as-needed (PRN) medication in an effort to address R1’s agitation. According to interviews conducted during the investigation, 911 was called to have R1 transported to the hospital to be evaluated. By the time paramedics arrived, the PRN had taken effect, and R1 had settled down. Paramedics contacted R1’s responsible party and informed the responsible party that it was suspected that R1 may have a urinary tract infection (UTI) and inquired whether R1’s responsible party wanted R1 to be transported to the hospital. R1’s responsible party declined transport of R1 to the hospital, as he/she did not believe it was necessary, since R1 was calm at the time.

According to evidence obtained during the investigation, the following day, R1’s responsible party transported R1 to the hospital, and medical records reflect that R1 was diagnosed with a UTI and hypernatremia [deficit of total body water relative to total body sodium level]. R1 was admitted and stabilized at the hospital. Subsequently, R1 was transferred to a skilled nursing facility (SNF) on 8/11/2023, where R1 remained until his/her death on 8/19/2023. R1’s death certificate reflects that the primary cause of death was vascular dementia with contributing factors of urinary tract infection & hypernatremia.

According to the Mayo Clinic and interview with medical personnel, lack of appetite and fluid consumption is common for persons with a diagnosis of dementia who are in cognitive and overall health decline. Hospital records that were reviewed indicate that R1’s hypernatremia likely resulted from R1’s diagnosis of dementia and the infection. Evidence obtained during the investigation indicates that R1 continued to consume water, but his/her water intake decreased during R1’s last few weeks at the facility, due to the progression of dementia and decline of R1’s cognitive state. Interviews yielded that, although R1’s fluid (water) consumption decreased, facility staff did not see signs of dehydration or have reason to believe R1 was becoming dehydrated.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 08-AS-20230925150942
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: 03/20/2024
NARRATIVE
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[3] It was also reported that R1 had an extreme rash with open sores on his/her entire body that had been present for at least ten months and were, reportedly, confirmed by lab results, to be scabies. Medical records reviewed during the investigation reflect that on 6/16/2023, samples were biopsied from two areas on R1’s body to be lab tested to determine the cause of the rash. The records reflect that the results were received on 6/20/2023, and R1’s responsible party was informed on 6/24/2023 that the rash was spongiotic dermatitis, which includes contact dermatitis, atopic nummular eczema, and drug reaction. Interviews and records yielded that facility staff had been applying prescribed medication to the rash.

In addition to the foregoing, the investigation revealed that R1’s responsible party repeatedly cancelled or declined appointments that were scheduled for a nurse practitioner from a mobile physician company to visit R1, which prevented R1 from being evaluated by a medically trained professional for conditions such as dehydration and observation of the ongoing rash.

The investigation did not yield evidence to conclude that facility staff did not seek timely medical attention or that action or inaction on the part of the licensee caused R1’s death.

It was also reported that the licensee did not maintain the facility free of pests. The investigation yielded that there may have been a few occasions when pests were observed in the facility. However, the investigation also yielded that the licensee was taking measures to address any issues with pests by having pest control treatment to occur in the facility.

The next allegation is that the licensee did not maintain a clean facility. It was reported that upon removal of the bed of a former resident, dirt and dead bugs were observed where the bed had previously been, and dust was observed in the facility. It was discovered during the investigation that there had been construction work occurring on the facility property, and items were, at times, not stored out of public view, which resulted in the accumulation of items around the facility.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 08-AS-20230925150942
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: 03/20/2024
NARRATIVE
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[4] During LPA’s unannounced visits, although it was observed that work had been occurring around the facility, inside the facility was observed to be clean. Additionally, interviews conducted did not yield evidence to conclude that the facility was not kept clean.

Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with Karina Ramirez, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit. Karina’s signature below serves as acknowledgment of receipt of copies of the report and rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 08-AS-20230925150942
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
CCR
87468.1(a)
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Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Staff offered to ensure that all staff participate in personal rights training. Proof of training will be provided to Community Care Licensing by the POC due date of 4/5/2024.
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This req't was not met as evidenced by:

Based on interviews, the licensee did not ensure that R1, 1 of 15 persons in care, was accorded dignity, which posed a potential personal rights risk to persons in care.
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Type B
04/05/2024
Section Cited
CCR
87219(a)
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Planned Activities. (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.
This requirement was not met as evidenced by:
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Staff offered to ensure that the facility's activity calendar is updated and posted in a visible place in the facility and activities are conducted in accordance with the calendar. Staff offered to submit a copy of the updated calendar reflecting activities actually conducted to Community Care Licensing by
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Based on interviews, the licensee did not ensure that activities were/are planned and provided for 15 of 15 residents, which poses a potential personal rights risk to persons in care.
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the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
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
09/25/2023 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20230925150942

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: 15DATE:
03/20/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Karina RamirezTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Licensee did not provide a refund to resident’s responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to conclude a complaint investigation into the above listed allegation. LPA was granted entry into the facility and met with Karina Ramirez, to whom LPA disclosed the reason for the visit.

The investigation consisted of a tour of the facility and interviews of facility staff and outside source.

Interviews conducted during the course of the investigation revealed that resident’s responsible party was provided a refund in accordance with Title 22 regulation.

Accordingly, we have found that the complaint allegation was unfounded, meaning that the allegation was false and/or is without a reasonable basis. Therefore, as to the above-listed allegation, the facility is in compliance with Title 22 regulations at this time, and we have dismissed the complaint.
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 08-AS-20230925150942
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: 03/20/2024
NARRATIVE
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An exit interview was conducted with Karina Ramirez, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to her at the conclusion of the visit. Karina’s signature below serves as acknowledgment of receipt of copies of the report and rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9