Lakeside Manor

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Angelica Boyles conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with caregiver Karina Ramirez. Administrator Herika Rico shortly joined the visit. The facility is licensed to serve 17 elderly residents age 60 and above 12 of whom may be non-ambulatory, 5 bedridden, and 15 residents who may be on hospice care. LPA, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was comfortable and complaint. Hot water temperature at taps accessible to clients were all compliant. (Continued on LIC 809-C) (Continued from LIC 809) There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records. The reviewed files contained required documents. Confidential records were stored in locked areas. The Administrator also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Herika Rico, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 27, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced case management visit to inspect the facility in response to the Licensee's request to increase the facility's capacity from 15 to 17 non-ambulatory residents in care. LPA Correia was greeted by Caregiver Melissa Burciaga, identified herself, and discussed the purpose of the visit with Caregiver Burciaga and Caregiver Liz Serrano, and Administrator Herika Rico joined the visit shortly later. An application for an increase of capacity from the current capacity of 15 non-ambulatory residents to 17 non-ambulatory residents was received by the Department on January 6, 2025. The application entailed changing two private room into shared rooms. The Fire Safety clearance was conducted and granted approval by the Lakeside Fire Protection District on April 24, 2025. During today’s visit, LPA conducted a facility tour and confirmed the details of the application request, facility sketch, and fire clearance. The completed change of capacity and non-ambulatory residents request will be forwarded to management for final review and approval. An exit interview was conducted with Administrator Herika Rico, to whom a copy of this report and the Licensee Rights (LIC9058 01/16) were provided at the end of the visit.the state’s words, verbatim · CDSS document, Apr 28, 2025

Allegation investigated: Facility did not issue required refund to resident's authorized representative.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings for the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Herika Rico. It was alleged that the Licensee did not provide Resident 1’s (R1’s) Responsible Party (RP) a full refund after discharge from the facility. A records review revealed R1 was admitted to the facility on February 2, 2022, subsequently R1 was voluntarily discharged on February 9, 2022, with no prior notice. Interviews conducted with Outside Source 1 (OS1), Staff 1 (S1) and a facility records review revealed the facility issued the RP a refund in an amount meeting the Department’s mandate. An interview conducted with OS1, and a prior complaint filed against the facility, alleged the Admission Agreement did not meet California Code of Regulations, Title 22, Division 6, Chapter 8, therefore there was no contractual agreement in place and Title 22 refund mandate was not warranted. [CONTINUED ON LIC 9099C] Unsubstantiated The Department’s investigation regarding the allegation that the Admission Agreement did not meet State mandate was determined to be unsubstantiated declaring R1’s Responsible Party (RP) was bound by the terms as defined with-in the agreement. [See LIC 811 for Confidential Names] Based on the Department's investigation there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Rico to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit.the state’s words, verbatim · CDSS document, Jul 3, 2024 · control 08-AS-20240429134128

Type of visit: Case Management - Other

LPA Correia conducted an unannounced visit to obtain signatures on an amended report. LPA identified herself to Administrator Rico, was granted entry into the facility, and explained the purpose of the visit. During today's visit LPA Correia obtained signatures on an amended report. An exit interview was conducted with Administrator Rico whom a copy of this report and the Licensee's Rights (LIC9058 01/16) was provided via electronic mail. LPA requested an email response as confirmation of receipt of the document.the state’s words, verbatim · CDSS document, Jul 3, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Debbie Correia, made an unannounced visit to conduct the required One-Year Inspection. LPA Correia was greeted by Herika Rico, identified herself and explained the purpose of the visit. The facility is licensed to serve 15 residents age 60 and above, 90 of whom may be non-ambulatory, 20 bedridden, and 20 residents who may be on hospice care. Resident records were reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, and Admission Agreement. The facility carbon monoxide and smoke alarms were last inspected on February 20, 2024. The facilities last disaster drill was conducted on April 1, 2024. During today’s visit, LPA Correia conducted a partial interior tour of the facility, resident and facility records reviews. An overall inspection of the facility began today, however, due to time constraints LPA was unable to complete the visit and will return at later time to conduct the remaining portion of this inspection. Based on today’s inspection, there are no deficiencies being cited. An exit interview was conducted and a copy of this report, and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) will be provided to Herika Rico whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 21, 2024

Allegation investigated: Staff did not ensure that resident was properly clothed. Staff did not provide activities for residents.

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with Karina Ramirez, to whom she disclosed the reason for the visit. Community Care Licensing (CCL) has investigated the above-listed complaint allegations. The investigation consisted of tours of the facility and interviews of facility staff and outside sources. It was reported that Resident 1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] was observed seated in the living area of the facility with a top and a diaper on, but no bottom item of clothing. Interviews conducted during the investigation confirmed that, on occasions, staff would seat R1 in his/her wheelchair in the common area of the home with a top item of clothing and an adult brief with no bottom clothing or covering on. Substantiated It was also alleged that facility staff did not provide activities for residents. It was reported that when the facility initially opened, licensees were good at providing activities and engaging the residents in activities. After a while, reportedly, licensees took a step back from the facility’s day to day operations; during that time period, activities ceased. Interviews conducted revealed that bingo is conducted periodically, but there is no set schedule, and the occurrences are random. Other than the occasional bingo games, interviews yielded that there are no activities provided for residents to participate in. Accordingly, the above identified allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted with Karina Ramirez, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit. Karina’s signature below serves as acknowledgment of receipt of copies of the report and rights. [2] were initiated and discontinued on a few occasions. The investigation yielded that on 8/7/2023, R1 became agitated at the facility and began kicking and punching his/her bedroom windows. Staff attempted to redirect R1 and administered an as-needed (PRN) medication in an effort to address R1’s agitation. According to interviews conducted during the investigation, 911 was called to have R1 transported to the hospital to be evaluated. By the time paramedics arrived, the PRN had taken effect, and R1 had settled down. Paramedics contacted R1’s responsible party and informed the responsible party that it was suspected that R1 may have a urinary tract infection (UTI) and inquired whether R1’s responsible party wanted R1 to be transported to the hospital. R1’s responsible party declined transport of R1 to the hospital, as he/she did not believe it was necessary, since R1 was calm at the time. According to evidence obtained during the investigation, the following day, R1’s responsible party transported R1 to the hospital, and medical records reflect that R1 was diagnosed with a UTI and hypernatremia [deficit of total body water relative to total body sodium level]. R1 was admitted and stabilized at the hospital. Subsequently, R1 was transferred to a skilled nursing facility (SNF) on 8/11/2023, where R1 remained until his/her death on 8/19/2023. R1’s death certificate reflects that the primary cause of death was vascular dementia with contributing factors of urinary tract infection & hypernatremia. According to the Mayo Clinic and interview with medical personnel, lack of appetite and fluid consumption is common for persons with a diagnosis of dementia who are in cognitive and overall health decline. Hospital records that were reviewed indicate that R1’s hypernatremia likely resulted from R1’s diagnosis of dementia and the infection. Evidence obtained during the investigation indicates that R1 continued to consume water, but his/her water intake decreased during R1’s last few weeks at the facility, due to the progression of dementia and decline of R1’s cognitive state. Interviews yielded that, although R1’s fluid (water) consumption decreased, facility staff did not see signs of dehydration or have reason to believe R1 was becoming dehydrated. [3] It was also reported that R1 had an extreme rash with open sores on his/her entire body that had been present for at least ten months and were, reportedly, confirmed by lab results, to be scabies. Medical records reviewed during the investigation reflect that on 6/16/2023, samples were biopsied from two areas on R1’s body to be lab tested to determine the cause of the rash. The records reflect that the results were received on 6/20/2023, and R1’s responsible party was informed on 6/24/2023 that the rash was spongiotic dermatitis, which includes contact dermatitis, atopic nummular eczema, and drug reaction. Interviews and records yielded that facility staff had been applying prescribed medication to the rash. In addition to the foregoing, the investigation revealed that R1’s responsible party repeatedly cancelled or declined appointments that were scheduled for a nurse practitioner from a mobile physician company to visit R1, which prevented R1 from being evaluated by a medically trained professional for conditions such as dehydration and observation of the ongoing rash. The investigation did not yield evidence to conclude that facility staff did not seek timely medical attention or that action or inaction on the part of the licensee caused R1’s death. It was also reported that the licensee did not maintain the facility free of pests. The investigation yielded that there may have been a few occasions when pests were observed in the facility. However, the investigation also yielded that the licensee was taking measures to address any issues with pests by having pest control treatment to occur in the facility. The next allegation is that the licensee did not maintain a clean facility. It was reported that upon removal of the bed of a former resident, dirt and dead bugs were observed where the bed had previously been, and dust was observed in the facility. It was discovered during the investigation that there had been construction work occurring on the facility property, and items were, at times, not stored out of public view, which resulted in the accumulation of items around the facility. [4] During LPA’s unannounced visits, although it was observed that work had been occurring around the facility, inside the facility was observed to be clean. Additionally, interviews conducted did not yield evidence to conclude that the facility was not kept clean. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Karina Ramirez, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit. Karina’s signature below serves as acknowledgment of receipt of copies of the report and rights. An exit interview was conducted with Karina Ramirez, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to her at the conclusion of the visit. Karina’s signature below serves as acknowledgment of receipt of copies of the report and rights.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 08-AS-20230925150942

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Apr 5, 2024

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This req't was not met as evidenced by: Based on interviews, the licensee did not ensure that R1, 1 of 15 persons in care, was accorded dignity, which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Staff offered to ensure that all staff participate in personal rights training. Proof of training will be provided to Community Care Licensing by the POC due date of 4/5/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Apr 5, 2024

Planned Activities. (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure that activities were/are planned and provided for 15 of 15 residents, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Staff offered to ensure that the facility's activity calendar is updated and posted in a visible place in the facility and activities are conducted in accordance with the calendar. Staff offered to submit a copy of the updated calendar reflecting activities actually conducted to Community Care Licensing by the POC due date.

Allegation investigated: Neglect resulted in pressure injury Neglect resulted in malnourishment

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings for the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Owner Matthew DelBruegge. On January 8, 2024, Community Care Licensing (CCL) received a complaint alleging neglect of Resident 1 (R1) resulted in pressure injury and neglect of R1 resulted in malnourishment. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to R1’s Physician Report, dated January 17, 2023, R1 has a mild cognitive impairment, is non-ambulatory, is on a special diet due to dialysis, can follow instruction and can communicate needs. According to allegation, on January 3, 2024, R1 was observed to have pressure injuries on the elbow and sacral area in which staging had not been determined but were alleged to have occurred as a result of neglect. Unsubstantiated Based on records reviewed, R1 moved into facility on December 6, 2023. Records showed, R1 was receiving wound care from Home Health Provider for elbow and sacral wound since October 2023. According to records, sacral wound being treated was as a Stage 2 pressure ulcer. Interview with Home Health provider confirmed R1 was receiving twice weekly visits from home health. Records reviewed also revealed that R1 was transferred to Hospice care as of December 26, 2023, due to requiring a higher level of care. Interview with caregivers revealed that R1 was rotated every two hours and changed as necessary. Interview with Hospice Agency revealed there were no concerns with the level of care provided to residents at the facility. Interview with Hospice also confirmed Hospice agency is now providing care to pressure injury. Interview with outside source revealed that there was no suspected neglect to R1. It was also alleged that facility neglect resulted in R1 being malnourished. Records reviewed revealed R1 could feed self. Interviews with staff revealed R1 only eats about half of their servings. Records reviewed revealed R1’s has declined cognitively since September of 2023 and has increased lethargy. Records also revealed R1’s appetite ranges from Good to Fair, week by week. Lastly, records reviewed revealed R1’s Body Mass Index is 19.1. According to the Center’s for Disease Control and Prevention (CDC) 19.1 is considered healthy weight. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Owner Matthew DelBruegge to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 08-AS-20240108103817

Allegation investigated: Licensee did not provide accorded refund. Licensee did not ensure removal of oxygen tanks from facility.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings on a complaint investigation regarding the above-mentioned allegations. LPA Correia was greeted by Caregiver Litzy Serrano and explained the purpose of the visit. The Department's investigation included staff and outside source interviews, as well as facility, resident, and outside source records reviews. It was alleged the Licensee did not provide Resident 1 (R1) (see LIC 811 Confidential Names List for identification) their accorded refund upon discharge from the facility. An Outside Source 1 (OS1) interview and records review revealed R1 was admitted to the facility on February 2, 2022, subsequently R1 was voluntarily discharged on February 9, 2022, with no prior notice. Interviews and a facility and resident records review revealed the Licensee required a 30-day written notice to be eligible for a refund of unused rent money received post the 30-day date provided on the notice of relocation minus any additional days a resident or a resident’s belongings remained at the facility. Unfounded Per Title 22 regulation, the Licensee was mandated to provide a refund of 80 percent of the Preadmission fee paid over $500. Outside source and staff interviews, as well as a facility and outside source records review, revealed the Licensee provided a refund, on R1's behalf, of an amount that exceeded the facility’s protocol and Title 22 mandate. It was also alleged the Licensee did not ensure removal of R1’s oxygen tanks from the facility. An interview with Outside Source 1 (OS1) revealed when R1 was discharged from the facility the Licensee did not provide three (3) of R1’s oxygen tanks with the transport agency. An interview with facility Staff 1 (S1) revealed that R1 received oxygen tanks by an Outside Agency 1 (OSA1) at the time R1 was admitted to the facility. The interview also revealed an oxygen tank provided by OSA1 was given to R1’s transport agency at discharge, and any other of OSA1’s property provided to the facility for R1’s care was retrieved by OSA1. An interview with an additional agency affiliated with OSA1 corroborated the deliverance of oxygen tanks to the facility the day of R1’s admission and upon retrieval after R1’s discharge, R1 had left the facility with an oxygen tank during transport. The interview with S1 also revealed the three (3) oxygen tanks in question were empty when they were brought to the facility with R1 upon arrival from out of state via ambulance transport. An interview with an additional Outside Source 2 (OS2) revealed they believed the oxygen tanks belonged to an Outside Agency 2 (OSA2) located out of State. OS2 also revealed they coordinated to have the tanks picked up from the facility on February 19, 2022, by a friend. An interview with OSA2 revealed they did not prescribe or provide R1 with Oxygen tanks. Additional records reviews revealed the Licensee had reached out to OS2 to facilitate the removal of R1’s three (3) oxygen tanks left behind. Based on the Department’s investigation the above-mentioned allegations were of the complaint were determined to be unfounded. An unfounded finding means that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the Department has dismissed the complaint allegations.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 08-AS-20231002121928

Type of visit: Case Management - Other

LPA Correia conducted an unannounced visit to obtain signatures on an amended report. LPA identified herself, was granted entry into the facility, and explained the purpose of the visit. During today's visit LPA obtained signatures on an amended report. An exit interview was conducted with RSC Rico to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) was provided via electronic mail. LPA requested an email response as confirmation of receipt of the document.the state’s words, verbatim · CDSS document, Oct 26, 2023

Allegation investigated: Licensee provided false advertisement. Licensee did not meet reporting requirements.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude the above listed complaint allegations. LPA Correia was greeted by Caregiver Anne Cabrejas, identified herself, and explained the purpose of the visit. A short time later RSC Rico arrived at the facility to conduct the visit. The Department's investigation included staff and outside source interviews, facility and outside source records reviews, and a facility tour. It was alleged the Licensee provided false advertisement. An outside source interview, facility record review, and a facility tour revealed Resident's 1 (R1’s) Responsible Party (RP) was provided a picture of the room R1 would be residing in prior to admission. A facility tour revealed although the picture appeared to be the same room, there was no comparison regarding the décor and/or appearance of the room depicted in the picture per LPA's observation during the facility tour. . Substantiated It was also alleged the Licensee did not meet reporting requirements. An interview with an outside source inquired if Community Care Licensing (CCL) had been notified by the Licensee regarding an incident that occurred at the facility that resulted in the Sheriff’s Department coming to the facility. The incident is an allegation within this complaint and is later discussed in the report. A facility records review revealed CCL did not receive an incident report, nor a verbal notification regarding the incident in question. Based on interviews, the above allegations are determined to be substantiated. A substantiated finding means the allegations are valid because the preponderance of the evidence standard has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on the LIC 9099-D. An exit interview was conducted with RSC Rico and a copy of this report along with Licensee/Appeal Rights was provided to RSC Rico(LIC 9058 01/16) and her signature below confirms receipt of the confirms receipt of the documents. Based on interviews, the above allegation was determined to be unsubstantiated. An unsubstantiated finding means the allegation could be valid but the preponderance of the evidence standard has not been met. An exit interview was conducted with RSC Rico and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided and signature below confirms receipt of the documents.the state’s words, verbatim · CDSS document, Oct 5, 2023 · control 08-AS-20231002121928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87706(a)(H)(1) · Plan of correction due date: Nov 30, 2023

Advertising Dementia...program and Environments... licensees who advertise,...special care..environments for residents with dementia...shall meet the following requirements: Physical environment ...that ensure a safe, secure...consistent environment for residents with dementia....include bedroom decor; architectural and safety features...lighting; colors... This requirement was not met as evidence by: Based on an interview, record review, and facility tour the Licensee did not provide accurate advertisement regarding R1's room. This poses a personal rights risk to 1 of 13 residents in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: RSC Rico and Licensee Cabuco will update photos as advertised to reflect current facility physical plant. Rico and Cabuco will provide CCL updated pictures used for advertising by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 30, 2023

Reporting Requirements. Each Licensee shall furnish..., including, but not limited to, the following: written report shall be submitted to...licensing ...an...person responsible...within seven days of the occurrence of any of the events specified in (A) through (D)....This report shall include the resident's name,...nature of event; attending physician's...,findings, and treatment,.. and disposition of the case. Any incident which threatens the welfare, safety or health...of a resident by staff or other residents, or unexplained absence... This requirement was not met as evidence by: Based on a facility records review the Licensee did not notify CCL of a required reported incident that occurred at the facility. This poses a personal rights risk to 1 of 13 residents in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: Licensee will seek CCL approved vendorized training regarding reporting requirements to be administered to both administrative and care staff. Licensee Cabuco will provide proof of training by POC due date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.