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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600864
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:55:43 PM

Document Has Been Signed on 12/12/2024 03:55 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:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:William "Zach" Pilkerton, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On December 12, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 12:33 PM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by William Pilkerton, Administrator and explained the purpose of the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 25 bedrooms and 21 bathrooms, kitchen, dining room, TV room, Nurses Lounge, Office, Beauty Salon, Patio, and back yard. All bedrooms had the required furniture and sufficient lighting. The facility was maintained at a comfortable temperature. Per interview with the Administrator, the facility's fire alarms are connected directly to the fire department. The fire alarm panel was observed to be in working order. The facility had the required carbon monoxide detectors which were observed to be in working order. The facility had the required 7 days of non perishables and 2 days of perishables on hand. No food was expired.

The following documents were gathered at the facility:
  • Administrator certificate for William Pilkerton
  • Certificate of Liability Insurance

The following documents shall be sent to the Regional Office by 12/19/2024:
  • Updated LIC 500
  • Control of Property

LPA Calandra reviewed 5 resident records. All were observed to be complete.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties

The Annual will be completed at a later date.

An exit interview was conducted. The report was reviewed with William Pilkerton, Administrator and a copy of the report along with Appeal rights left at the facility.


SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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Document Has Been Signed on 12/12/2024 03:55 PM - It Cannot Be Edited


Created By: John Calandra On 12/12/2024 at 03:11 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: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, a faucet in residents room did not supply hot water, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee shall have faucet fixed and submit proof of fixture to the Regional Office by POC due date along with a plan on how the facility will prevent this issue from occurring in the future.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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