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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600864
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:35:08 PM


Document Has Been Signed on 12/06/2023 12:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:LAKEVIEW LODGEFACILITY NUMBER:
415600864
ADMINISTRATOR:CAMPBELL, ROSALINDAFACILITY TYPE:
740
ADDRESS:530 LAKEVIEW WAYTELEPHONE:
(650) 369-7476
CITY:EMERALD HILLSSTATE: CAZIP CODE:
94062
CAPACITY:49CENSUS: 28DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rosalinda CampbellTIME COMPLETED:
12:45 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with administrator Rosalinda Campbell and explained the purpose of today's visit.

LPA was allowed entry into the facility. The facility is considered two levels attached with a ramp and a basement level which is accessible from the parking lot or stairs located in the kitchen. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is locked from resident access. Knives are stored within the kitchen behind locked and closed door. Perishable and non-perishable food items are observed as in place. LPA observed the the medications as in place and current to residents reviewed. The first aid kit is maintained in the medication room and is complete with required items. LPA observed a pull alarm fire system, fire extinguishers through out the facility inspected 09/19/23, smoke detector/carbon monoxide detectors, fire sprinklers through out, and central heating in the facility as in place. PPE and additional food supplies are observed as in place. Laundry room is also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was taken on two common sinks measuring at 108F. LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Cleaning supplies are observed behind a locked janitor's closet not accessible to residents. Additional cleaning supplies, food supplies, laundry area, COVID PPE, and resident incontinence supplies are observed in place in the basement area of the facility.

LPA reviewed resident files and staff files which are all current. The facility does not handle resident money. Liability insurance is observed as in place and current as reviewed on this date. Administrator certificate is current expiring 02/07/2025 as observed in place.

The following items are requested to be submitted by 12/13/2023:

- Infection Control Plan (LIC9282)
- Designation of Facility Responsibility (LIC308)
- Personnel Report (LIC500)
- Updated administrator Certificate
- Emergency Disaster Plan (LIC610E)
- Copy of certificate of liability insurance

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Report reviewed with administrator.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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