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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604472
Report Date: 10/05/2023
Date Signed: 10/12/2023 07:55:20 AM

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
02/17/2022 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20220217120815
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:
10/05/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Resident Service Coordinator (RSC) Herika RicoTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Admission Agreement was not complete.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation regarding the above-mentioned allegation. LPA Correia was greeted by Resident Service Coordinator (RSC) Rico, identified herself, and explained the purpose of the visit.

The Department's investigation included staff and outside source interviews and a facility records review.

It was alleged that facility Staff 1 (S1) did not provide Resident’s 1 (R1's) Responsible Party (RP) with a complete version of R1’s signed Admission Agreement. A record review revealed R1’s Admission Agreement was provided to R1’s RP, however the copy had multiple pages with areas that were not legible or blank, due to what appeared to be the facility's printer running out of ink.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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 6
Control Number 08-AS-20220217120815
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: 10/05/2023
NARRATIVE
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Based on staff and outside source interviews and a facility records review, the above listed allegation was determined to be substantiated. A substantiated finding means the Preponderance of Evidence standard has been met.

LPA Correia conducted an exit interview with RSC Rico At the time of the exit interview RSC Rico was provided a copy of the reports and Licensee/Appeal Rights (LIC 9058) and signature on this report acknowledges receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/17/2022 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20220217120815

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:
10/05/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Resident Service Coordinator (RSC) Herika RicoTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility does not have a sink to wash hands.
Resident was not provided water.
The facility has unlicensed construction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation regarding the above-mentioned allegations. LPA Correia was greeted by Resident Service Coordinator (RSC) Rico, identified herself and explained the purpose of the visit.

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

It was alleged the facility does not have a sink to wash hands. A facility tour and a facility records review revealed the facility has an expansion consisting of three private resident rooms. During the tour, LPA observed the resident rooms do not have a common bathroom or sinks within the expansion however, the facility has a total of 8 sinks located in the other 2 adjacent buildings.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20220217120815
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: 10/05/2023
NARRATIVE
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It was also alleged that facility staff did not provide Resident 1 (R1) water. An interview with Outside Source 1 (OS1) revealed that they arrived at the facility that R1 immediately asked for water. OS1 revealed they felt R1 was parched and deprived of water by facility staff. A resident records review revealed R1 was on Hospice and due to R1’s current health status, at the time of OS1’s visit, R1’s physician’s orders was to be provided moist mouth swabs. An interview conducted with facility Staff 1 (S1) revealed because R1 was at high risk of aspirating staff provided moist mouth swabs and ice chips. An additional interview with Outside Source 2 (OS2) corroborated it is not unusual to refrain from giving any fluids or food by mouth to individuals with a health status as R1.

Lastly, it was alleged the facility had unlicensed construction. An outside source records review revealed that the facility had undergone upgrades conducted by a licensed contractor. The record review also revealed the construction consisted of upgrades such as new flooring and new cabinetry, and the property was not structurally altered, and did not require city permits. A tour of the facility corroborated the construction was not structural and consisted of upgrades.

Due to lack of corroborating evidence, the findings regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid there is not a preponderance of evidence to prove that the alleged violations occurred.

LPA conducted an exit interview with RSC Rico. At the time of the exit interview a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016) were provided. Signature on this report acknowledges receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20220217120815
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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/06/2023
Section Cited
CCR
87507(a)(1)(B)
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(a)The licensee shall complete... admission agreement...), with each resident or the resident's representative, if any. The text of the admission agreement..., shall be: (B) Written in clear, understandable, coherent, and unambiguous language... and shall be appropriately divided with each section appropriately titled.

This requirement was not met as evidenced by:
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RSC Rico and Licensee Cabuco will coordinate a reoccurring delivery of printer ink, as well as keeping printed Admission Agreements and ensuring all language included is legible.

RCS Rico and Licensee Cabuco will provide proof of completion by POC due date.
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Based on a record review the Licensee did not provide the Responsible Party a legible copy of R1's Admission Agreement. This poses a personal rights risk to 1 out of 13 Residents.

This is an amended version of the original report dated 10/5/2023.
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CCR
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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: Jennifer LottTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6