011400369-7-15-2020-15-AS-HHUL-BZHS2L-20210327132940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011400369
Report Date: 07/15/2020
Date Signed: 07/15/2020 11:33:38 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2020 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200521151322

FACILITY NAME:	LAKE PARK		FACILITY NUMBER:	011400369
ADMINISTRATOR:	MINDY HAN		FACILITY TYPE:	741
ADDRESS:	1850 ALICE		TELEPHONE:	(510) 835-5511
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94612
CAPACITY:	275	CENSUS: 166	DATE:	07/15/2020
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Mindy Han, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility failed to safeguard resident's valuables
Facility failed to notify resident's condition to the responsible party
Facility failed to observe changes in the resident's condition prior to the resident sustaining a fall

INVESTIGATION FINDINGS:

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On 7/15/2020 at 11:05am, Licensing Program Analyst contacted facility to deliver findings for the above allegations via tele-visit due to shelter in place directed by the Governor. LPA conducted tele-visit via facetime with Executive Director, Mindy Han.

During the course of investigation, LPA obtained information, collected documents and interviewed staff and witness. Based on information provided by reporting party (RP), facility failed to safeguard resident’s (R1) valuables. Based on record review, admission agreement revealed that the facility is not liable for resident’s personal property. Interview with witness (W1) revealed R1 is a “pack rat” and would oftentimes misplaced items or would gift items to friends but R1 would forget R1 gave it away.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200521151322

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKE PARK	FACILITY NUMBER: 011400369
	VISIT DATE: 07/15/2020

NARRATIVE

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Based on information obtained by RP, facility did not notify responsible party of R1’s condition. Based on interview with W1, W1 was notified of R1’s fall immediately that occurred on 3/27/2019. W1 stated that facility is good about notifying any concerns regarding R1 and facility holds quarterly meetings with W1.

Based on information obtained by RP, facility failed to observe changes in the resident's condition prior to the resident sustaining a fall. Based on information from S1 and W1, R1 is independent. W1 stated R1 has had an unsteady gate over the years. It was revealed during the interview with W1 that facility suggested R1 be moved to assisted living, however, W1 stated R1 refused and wanted to remain in the independent living.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of report will be emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

LIC9099 (FAS) - (06/04)

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