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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604472
Report Date: 10/05/2023
Date Signed: 12/29/2023 04:21:30 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
10/02/2023 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20231002121928
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:
01:15 PM
MET WITH:Residential Service Coordinator (RSC) Herika RicoTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee provided false advertisement.
Licensee did not meet reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude the above listed complaint allegations. LPA Correia was greeted by Caregiver Anne Cabrejas, identified herself, and explained the purpose of the visit. A short time later RSC Rico arrived at the facility to conduct the visit.

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

It was alleged the Licensee provided false advertisement. An outside source interview, facility record review, and a facility tour revealed Resident's 1 (R1’s) Responsible Party (RP) was provided a picture of the room R1 would be residing in prior to admission. A facility tour revealed although the picture appeared to be the same room, there was no comparison regarding the décor and/or appearance of the room depicted in the picture per LPA's observation during the facility tour.

.

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: 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: 1 of 6
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: 10/05/2023
NARRATIVE
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It was also alleged the Licensee did not meet reporting requirements. An interview with an outside source inquired if Community Care Licensing (CCL) had been notified by the Licensee regarding an incident that occurred at the facility that resulted in the Sheriff’s Department coming to the facility. The incident is an allegation within this complaint and is later discussed in the report. A facility records review revealed CCL did not receive an incident report, nor a verbal notification regarding the incident in question.

Based on interviews, the above allegations are determined to be substantiated. A substantiated finding means the allegations are valid because the preponderance of the evidence standard has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on the LIC 9099-D.

An exit interview was conducted with RSC Rico and a copy of this report along with Licensee/Appeal Rights was provided to RSC Rico(LIC 9058 01/16) and her signature below confirms receipt of the 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: 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
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
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
11/30/2023
Section Cited
CCR
87706(a)(H)(1)
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Advertising Dementia...program and Environments... licensees who advertise,...special care..environments for residents with dementia...shall meet the following requirements: Physical environment ...that ensure a safe, secure...consistent environment for residents with dementia....include bedroom decor; architectural and safety features...lighting; colors...

This requirement was not met as evidence by:
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RSC Rico and Licensee Cabuco will update photos as advertised to reflect current facility physical plant. Rico and Cabuco will provide CCL updated pictures used for advertising by POC due date.
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Based on an interview, record review, and facility tour the Licensee did not provide accurate advertisement regarding R1's room.

This poses a personal rights risk to 1 of 13 residents in care.
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Request Denied
Type B
11/30/2023
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements. Each Licensee shall furnish..., including, but not limited to, the following: written report shall be submitted to...licensing ...an...person responsible...within seven days of the occurrence of any of the events specified in (A) through (D)....This report shall include the resident's name,...nature of event; attending physician's...,findings, and treatment,.. and disposition of the case. Any incident which threatens the welfare, safety or health...of a resident by staff or other residents, or unexplained absence...

This requirement was not met as evidence by:
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Licensee will seek CCL approved vendorized training regarding reporting requirements to be administered to both administrative and care staff.

Licensee Cabuco will provide proof of training by POC due date.
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Based on a facility records review the Licensee did not notify CCL of a required reported incident that occurred at the facility.

This poses a personal rights risk to 1 of 13 residents in care.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
10/02/2023 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20231002121928

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:
01:15 PM
MET WITH:Resident Service Coordinator (RSC) Herika RicoTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee did not provide a safe environment.
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 RSC Rico, identified herself, and explained the purpose of the visit.

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

It was alleged the facility did not provide a safe environment. An interview with an Outside Source 1 (OS1) revealed an individual, later revealed as maintenance staff, was observed staring into Resident’s 1 (R1’s) room, and appeared to be a ‘peeping Tom’. During this incident law enforcement was called to the facility and investigated the incident. Interviews conducted with facility staff and an outside source, as well as an outside source records review revealed no evidence of mal intent by the individual that was seen looking into R1’s room.

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: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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 6
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: 10/05/2023
NARRATIVE
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3
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Based on interviews, the above allegation was determined to be unsubstantiated. An unsubstantiated finding means the allegation could be valid but the preponderance of the evidence standard has not been met.

An exit interview was conducted with RSC Rico and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided and signature below 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: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6