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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600864
Report Date: 12/02/2022
Date Signed: 12/02/2022 12:26:31 PM


Document Has Been Signed on 12/02/2022 12:26 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
SF COASTAL AC/SC, 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: 29DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rosalinda CampbellTIME COMPLETED:
12:30 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit focused on COVID infection control. LPA met with licensee/administrator Rosalinda Campbell and explained purpose of today's visit.

Upon entry LPA was COVID screened via questions and had temperature taken. LPA signed in as well. Prior to entry, LPA did observe COVID postings on the front door entering the facility. LPA toured facility's building and grounds. LPA observed COVID postings through out the facility. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is current. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Fire extinguishers are observed as being inspected on 08/25/2022. LPA observed three extinguishers and all three are charged and dials read as within specifications . Facility ambient temperature is comfortable. Facility lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped properly. Water temperature is tested at 108F in two common bathroom adjacent to the dining room. Of the resident rooms observed, they equipped with required furniture and light fixtures. Non-slip mats and grab bars are present in the designated shower room. Liquid soap is available and paper towels in resident bathrooms. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. Staff are observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact is reviewed as current. Administrator certificate is observed as current expiring on 02/02/2023. Facility does not handle resident monies. Entire staff and residents have been vaccinated.

The following updated forms are requested to be submitted to CCLD by 12/09/2022:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Copy of administrator certificate

No citations issued. Report is reviewed with Rosalinda Campbell.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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