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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600864
Report Date: 06/18/2025
Date Signed: 06/24/2025 02:14:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2025 and conducted by Evaluator John Calandra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250417161453
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: 31DATE:
06/18/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Zach Pilkerton, Administrator and Fe Arnaiz, Administrator TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Neglect/lack of supervision by facility staff led to the death of a resident.
Facility failed to seek timely medical attention for R1
INVESTIGATION FINDINGS:
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********************************************THIS IS AN AMENDED REPORT**********************************************

On 6/18/2025, Licensing Program Analyst (LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint received by the Department on 4/17/2025. LPA Calandra was greeted by Administrator, Fe Arnaiz and explained the purpose of the visit.

Complaint alleged that neglect/lack of supervision by facility staff led to the death of a resident. Based on interviews, around 12AM, facility staff conducted a nighttime check on R1. At around 1:38 AM, R1 left their room and was later found deceased outside the facility at 4:47 AM. Based on the Department’s review of documents and interviews conducted, it was found that facility staff did not check in on R1 every hour per the facility’s policy, resulting in them being able to leave the facility unassisted and being found outside hours after staff’s last check-in to be deceased.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 14-AS-20250417161453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/18/2025
NARRATIVE
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***********************************************This is an Amended Report*************************************************

Complaint alleged that the facility failed to seek timely medical attention for R1. Based on interviews, staff found R1 outside of the facility and carried R1 inside. Based on interviews conducted, the Department determined that facility staff were aware that R1 was not breathing when found outside and waited to perform CPR until 911 was called which was approximately 40 minutes after R1 was found unresponsive and not breathing as staff were attempting to locate R1’s Do Not Resuscitate(DNR) order which R1 did not have.

The Allegations above are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegations are valid because the preponderance of evidence standard has been met. The following deficiencies were cited on 9099-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 immediate $500 civil penalty was assessed due to the deficiencies resulting in the death of a resident.

Additional Civil Penalties may be assessed at a later date.

An exit interview was conducted.

This report was reviewed with the Administrator and a copy of the report along with Appeal Rights was left at the facility. Report sent via email to Administrator on 6/24/2025.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20250417161453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f)(1): Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code.

This requirement is not met as evidenced by:
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Licensee to submit training plan, including roster of staff who attended training, and content of training, including information on trainer.
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Based on interviews, the facility failed to provide care and supervision by not checking in on R1, which is an immediate health, safety, or personal rights risk to persons in care.
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Type A
06/19/2025
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including..

This requirement is not met as evidenced by:
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Licensee to submit training plan, including roster of staff who attended training, and content of training, including information on trainer.
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Based on interviews, the licensee did not immediately telephone 911 when it was determined that R1 was not breathing, which is 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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3