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Inspection visit

Follow-up on corrections

LAKEVIEW LODGELicense 4156008642 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

On 6/24/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to a secondary investigation by the Department. LPA Calandra was greeted by Zach Pilkerton, Administrator and explained the purpose of the visit. Through the course of the Department’s investigation into the death of a resident, R1, it was determined that staff were locking resident,(R2) in their room during the evening as they were a wander risk. However, the Needs and Services plan of R2 was not formalized and signed by resident's responsible party. The facility did not properly address R2's wandering needs. This poses an immediate health, safety or personal rights risk to persons in care. A Type A citation was issued for this violation. Based on interviews and observations, facility staff locked R2 by tying the door knob to the hand rail to prevent them from wandering around the facility. Video footage shows that another resident, R3 was also locked in their room using a device tied from the door knob to the hand rail. Residents in all residential care facilities for the elderly shall have the right to leave or depart the facility at any time. This is an immediate health, safety, or personal rights risk to persons in care. A Type A citation was issued for this violation. The following deficiencies were cited on 809-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 exit interview was conducted. A copy of this report along with Appeal Rights was left at the facility.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87463(i)Type A

    Hold reappraisal meeting on changes

    87463(i) Reappraisals: When there is significant change in condition... Definitions, or once every 12 months.., the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative...This requirement is not met as evidenced by: Based on document review, R2 had a reappraisal mentioning wandering, but it was not discussed with resident's responsible party, which is an immediate health, safety and personal rights risk to persons in care.

  • 87468.1(a)(6)Type A

    Freedom to leave and not be locked in

    87468.1(a)(6) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time...This requirement is not met as evidenced by: Based on interviews and observations, the Licensee did not ensure that R2 and R3 had the right to leave their room at night by locking them in their rooms by tying the door knob to the hand rail, which is an immediate health, safety and personal rights risk to persons in care.

  • 87405(d)(2)Type A

    Conformance with applicable laws and regulations

    87405(d)(2) Administrator - Qualifications and Duties... The administrator shall have the qualifications..(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requrement is not met as evidenced by: Based on interview, ADM denied having knowledge that staff are locking resident door. for over 12 hours and denied seeing the tie before. ADM stated that he/she did not know if S2 was interviewed and did not speak to S2 about the incident. S2 was written up/cited by law enforcement. ADM did not know what S2

FAQ · About this visit

Common questions about this visit

What happened during the June 24, 2025 inspection of LAKEVIEW LODGE?

This was an other inspection of LAKEVIEW LODGE on June 24, 2025. 2 citations were issued: 2 Type A (serious).

Were any citations issued to LAKEVIEW LODGE on June 24, 2025?

Yes, 2 citations were issued (2 Type A, 0 Type B). The first citation was for: "87463(i) Reappraisals: When there is significant change in condition... Definitions, or once every 12 months.., the lice..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.