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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600864
Report Date: 06/26/2025
Date Signed: 06/26/2025 10:55:24 PM

Document Has Been Signed on 06/26/2025 10:55 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/
DIRECTOR:		CAMPBELL, ROSALINDAFACILITY TYPE:
740
ADDRESS:530 LAKEVIEW WAYTELEPHONE:
(650) 369-7476
CITY:EMERALD HILLSSTATE: CAZIP CODE:
94062
CAPACITY: 49CENSUS: 32DATE:
06/26/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:40 PM
MET WITH:Fe Arnaiz and William Zach Pilkerton ]TIME VISIT/
INSPECTION COMPLETED:
11:00 PM
NARRATIVE
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On 6/26/2025, Licensing Program Analysts(LPAs) John Calandra, Simi Rai, and Manuel Monter, arrived at the facility to conduct a Case Management visit to cite additional deficiencies discovered during the Department's investigation of a complaint #14-AS-20250417161453 received on 4/17/2025. LPAs were greeted by Fe Arnaiz (ADM1) and William Zach Pilkerton (ADM2), and explained the purpose of the visit.

During the visit, LPAs toured the physical plant inside and outside. LPAs reviewed 32 resident files (R1-R32) including Centrally Stored Medication Records, Medication Administration Record (MAR) for January 2025 - March 2025 and centrally stored medications at the facility.

Based on the review of R1's Physician's report dated 9/3/2024 which stated R1 has a dual diagnosis of Mental Illness and neurocognitive disorder. Based on review of the facility's plan of operation page 16, "residents determined by their physicians to have a primary diagnosis of mental disorder unrelated to Dementia shall not be accepted or retained." R1 was admitted to the facility on 11/11/2024.

On 3/6/2025, Staff S4 was interviewed. Staff S4 stated, he/she conducted a routine check at 4:00am where he/she observed R1 to be in his/her room lying on his/her bed. Based on evidenced reviewed, resident R1 was observed outside of the facility at 1:38am-4:47am. Staff did not observe resident during this time frame. A Type A citation was issued for this violation during today's visit.

Continuation on LIC 809-C, Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/26/2025 10:55 PM - It Cannot Be Edited


Created By: John Calandra On 06/26/2025 at 07:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LAKEVIEW LODGE
FACILITY NUMBER: 415600864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2025
Section Cited
CCR
87208(a)

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87208 Plan of Operation (a)The licensee shall have and maintain....The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so ...This requirement is not met as evidenced by
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The Licensee will submit a written plan of action on how they will ensure they are following their plan of operation.
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Based on record review, the facility did not follow their plan of operation. The facility's program description states “Residents determined to have their physician diagnosis of mental disorder, unrelated to dementia shall not be accepted or retained. R1s primary diagnosis
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(con't) was schizophrenia, dementia, confusion, aggressive behavior and harm to self and will require supervision, which pose/poses an immediate health, safety and personal rights risk to residents in care.
Type A
06/27/2025
Section Cited
CCR87207

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87207 False Claims No licensee, officer or employee of a licensee shall make…any false or misleading statement regarding the facility…This requirement is not met as evidenced by: Based on interview, S2 stated he/she checked R1 at 4:00am and later admitted that he/she lied. S1 was interviewed
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The Licensee will submit a plan of action on how false statements are not made regarding care that is being provided at the facility.
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& stated CPR was administered prior to 911 call, however, S1 stated to SMCSO deputies he/she did not perform CPR. Administrator denied knowledge and witnessing that staff ties the door shut. On 5/14/25 ADM 2 was interviewed and admitted he has remote
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(con't) access to facility cameras to redirect staff. However during investigation, ADM2 denied having knowledge of staff's actions at night. which pose/poses an immediate health, safety and personal rights risk to persons in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LAKEVIEW LODGE
FACILITY NUMBER: 415600864
VISIT DATE: 06/26/2025
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Page 2 of 2.

Based on interview of Administrator, Administrator did not have the knowledge to provide appropriate care and supervision to residents. Administrator denied having knowledge that staff are locking resident door for over 12 hours and denied seeing the door secured with a bedsheet. On 5/14/25 ADM 2 was interviewed and admitted he has remote access to facility cameras to redirect staff. However during investigation, ADM2 denied having knowledge of staff's actions at night. A Type A citation was issued for this violation.

During today's visit, LPAs requested and received copies of the following documents:
  • All Resident records - Identification Emergency Contact, Appraisal Needs and Services Plan, LIC602A Physicians Report
  • Centrally Stored Medication logs and Medication Administration Records form January- March 2025.
  • LIC 500 Personnel Summary Report

During today's visit, 809-D page from 6/24/2025, Case Management was Amended to update the language in the deficiency statement. Changes were discussed with facility representative.

The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

An exit interview was conducted. This report was reviewed with facility administrator and a copy of the report along with Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4