Community Care Licensing

Document Has Been Signed on 12/23/2024 03:46 PM - It Cannot Be Edited

FACILITY NAME:	LAKEVIEW LODGE		FACILITY NUMBER:	415600864
ADMINISTRATOR/ DIRECTOR:	CAMPBELL, ROSALINDA		FACILITY TYPE:	740
ADDRESS:	530 LAKEVIEW WAY		TELEPHONE:	(650) 369-7476
CITY:	EMERALD HILLS	STATE: CA	ZIP CODE:	94062
CAPACITY: 49		CENSUS: 32	DATE:	12/23/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	William "Zach" Pilkerton, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

SUPERVISORS NAME: Andrea Medlin LICENSING EVALUATOR NAME: John Calandra LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024

Link to Parent Document Below:

FACILITY NAME: LAKEVIEW LODGE	FACILITY NUMBER: 415600864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/23/2024

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview of Administrator, Zach Pilkerton, S1's TB results/Health Screening Report were not present at the facility and could not be reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to submit a copy of S1's TB results/Health Screening Report by the Plan of Correction due date. Administrator will also ensure that S1's file is always on site and available for review.

SUPERVISOR'S NAME: Andrea Medlin LICENSING EVALUATOR NAME: John Calandra LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024

Link to Parent Document Below:

FACILITY NAME: LAKEVIEW LODGE	FACILITY NUMBER: 415600864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/23/2024

Type B

Section Cited

CCR

87415(a)

(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview of the Administrator, staff providing night supervision are familiar with the facility's planned emergency procedures, however no documentation of said training was available for review by the LPA, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2025
	Plan of Correction
1 2 3 4	Licensee/Administrator to work with someone to develop a training plan that will show topics covered, dates, and list of attendees by the Plan of Correction due date.

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview with Administrator, the facility has conducted quarterly emergency drill trainings but does not have documentation of them, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2025
	Plan of Correction
1 2 3 4	Licensee/Administrator to conduct a quarterly emergency drill and send the following information to CCLD: date of training, list of attendees, and content covered by the Plan of Correction due date.

SUPERVISOR'S NAME: Andrea Medlin LICENSING EVALUATOR NAME: John Calandra LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024

Link to Parent Document Below:

FACILITY NAME: LAKEVIEW LODGE	FACILITY NUMBER: 415600864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/23/2024

Type B

Section Cited

HSC

1569.695(d)

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the facility's LIC 610E(Emergency and Disaster Plan) was last updated on 12/9/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2025
	Plan of Correction
1 2 3 4	Licensee/Administrator to submit updated LIC 610E form to CCLD by the Plan of Correction due date. Administrator to add to his calendar a date that he will update the LIC 610E.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Andrea Medlin LICENSING EVALUATOR NAME: John Calandra LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024