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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600864
Report Date: 07/02/2025
Date Signed: 07/02/2025 10:06:21 AM

Document Has Been Signed on 07/02/2025 10:06 AM - 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: 33DATE:
07/02/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Zach PilkertonTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
NARRATIVE
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On July 02, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a unannounced Case Management – Health Check inspection visit. LPA met with the Administrator (ADM) Zach Pilkerton and disclosed the purpose of the inspection. There were 33 residents in care and 11 staff members present at the time of the inspection.

LPA initiated a walk-through of the facility, accompanied by the Administrator.

LPA inspected random resident rooms. LPA inspected attached bathrooms in these random rooms. The hot water temperature at the sink faucets measured between 112.3°F and 112.6°F. LPA inspected common areas and observed eight (8) residents sitting in the front room, seven (7) residents watching TV in the TV room, and one (1) resident in the dining room. LPA inspected the kitchen next to the front lobby area. The refrigerator and freezer were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. LPA inspected the pantry storage and laundry area in the basement, one level below the main floor.

LPA toured the outside areas and found passageways free of obstructions, and without any blocking or tripping hazards. No accessible bodies of water were observed.

LPA observed locked centrally stored medication cart in the medication room. Medications were organized separately for each resident. At 09:10 AM, Centrally Stored Medication Records were reviewed, and a medication count check was performed. LPA observed that the medication count for one (1) bedtime + dinner narcotic medication for one resident (R1) was found to be inaccurate and one less day of medication was administered to R1 for this medicine.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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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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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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: 07/02/2025
NARRATIVE
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The start date of this medication was 06/22/2025 and today’s date is 07/02/2025. Ten (10) days of medication should have been administered to R1 but only 9 days of medication were administered to R1. The MAR for this medication was reviewed and the entry for 06/29/2025 was not initialized.

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to the Administrator, Zach Pilkerton, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 10:06 AM - It Cannot Be Edited


Created By: Kiran Jain On 07/02/2025 at 09:42 AM
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: 07/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2025
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care (c) If the resident's physician has stated…facility staff designated… (2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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The Administrator will submit the plan for POC to CCLD by 07/03/2025.
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Based on observation, interview, and record review, the Administrator did not ensure one medication Lorazepam was administered correctly to resident (R1), which poses an immediate health, safety or personal rights risk to persons 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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