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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 08/27/2021
Date Signed: 08/27/2021 02:50:46 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: 149DATE:
08/27/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Mindy Han, AdministratorTIME COMPLETED:
12:35 PM
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On 08/27/21 at 11:45 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health and safety inspection and met with administrator (ADM) Mindy Han. LPA explained the purpose of the visit with ADM.

LPA observed routine COVID-19 symptom checks done by the on duty security staff at the front entrance. Hand sanitizers, additional face masks & temperature probe were observed used for COVID-19 symptom checks. COVID-19 signages were observed posted in the front entrance as reminders for residents, staff & visitors to wear face masks, practice proper hand washing/disinfecting, cough/sneeze etiquette, social distancing. LPA observed 4 x 7 plastic partitions in the front entrance to ensure safe distancing is practiced by residents, staff and visitors. LPA observed staff and residents wearing face masks. LPA toured the facility with administrator. LPA observed sufficient food, paper and PPE supplies in the kitchen and various storage areas. Food supplies are ordered by dining supervisor & delivered weekly to the facility. LPA observed facility had adequate lighting. Dining tables were covered with white linens distanced six feet apart and decorated with fresh cut flowers. LPA observed bathrooms had adequate paper and soap supplies. LPA also observed comfortable temperature maintained at 73 degrees Fahrenheit per thermostat reading. LPA obtained documents (current employee/resident rosters, assisted living staff schedule, house keeping staff schedule, and maintenance staff schedule). Sufficient staffing was observed during visit. Pathways and hallways were observed free of obstruction and fire hazards. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. Due to a COVID-19 positive case reported on 08/26/21 to Public Health & CCLD, LPA did not conduct interviews during visit.

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: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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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