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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:44:35 PM

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: 147DATE:
07/26/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Tammy Hauck, Executive DirectorTIME COMPLETED:
04:00 PM
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On 07/26/21 at 2:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health and safety inspection and met with Executive Director (ED) Tammy Hauck. LPA explained the purpose of the visit with ED.

LPA was screened at the front entrance with routine COVID-19 symptom checks done by the on duty staff. LPA toured the facility with ED and Director of Nursing (DN). LPA observed facility had sufficient food supplies in the kitchen and dining supervisor (DS) stated that food supplies are ordered & delivered weekly. LPA observed bathrooms has sufficient soap and paper towel supplies. LPA observed dining areas had round tables with white linen covers distanced six feet apart and decorated with fresh cut carnations. LPA also observed bathroom walls repainted. ED stated fire doors will be upgraded without pegs for improved fire safety. LPA obtained copies of menus, current resident roster (assisted living), and dietary staff schedule. Sufficient staffing was observed during visit. Pathways and hallways were observed free of obstruction and fire hazards.

LPA interviewed 5 residents during visit. LPA observed residents clean, well groomed and comfortable in their apartments. LPA obtained documents (current employee roster, assisted living staff schedule, house keeping staff schedule, and maintenance staff schedule) during visit. LPA also obtained copies of menu, resident roster (assisted living), and dietary staff schedule. ED stated the next residents' council meeting will be held on August 2, 2021 at 4-5 PM. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during inspection. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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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