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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 03/17/2021
Date Signed: 03/17/2021 11:46:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAKE PARKFACILITY NUMBER:
011400369
ADMINISTRATOR:MINDY HANFACILITY TYPE:
741
ADDRESS:1850 ALICETELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 151DATE:
03/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mindy Han, AdministratorTIME COMPLETED:
11:00 AM
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On 03/17/21 at 10:15AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced Health and Safety check and met with administrator. Due to a system glitch, this report could not be opened at the facility for administrator to sign. LPA advised administrator that she will email a copy of the report to her. Administrator agreed to sign the report, scan and email it back to the LPA on the same day. LPA will email completed report back to administrator for her files.

During the health and safety check, LPA observed a total of 5 staff members and 8 residents at the facility. LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, activity room and common areas. LPA obtained a copy of the latest personnel and residents rosters from administrator. LPA observed sufficient perishable & non-perishable food, paper, water, PPEs and emergency supplies at the facility. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies were observed during the health and safety check.

Exit interview conducted and a copy of this report provided to administrator via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021
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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