011400369-9-24-2021-15-AS-DPAO-C76RVT-20210924132206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 09/24/2021
Date Signed: 09/24/2021 01:22:27 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 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: 152	DATE:	09/24/2021
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Tammy Hauck, Executive Director		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/24/21 at 12:15PM, 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 staff wearing face masks. LPA observed COVID-19 signages posted in common areas as reminders for staff and residents to wear face masks, practice proper cough/sneezing etiquette, frequent hand sanitizing/hand washing, social distancing, etc. LPA received updated resident roster, assisted living staff schedule, housekeeping staff schedule, and maintenance staff schedule, from staff during visit. LPA toured the facility with ED. Comfortable temperature was observed maintained at 73 degrees F. LPA observed adequate lighting at the facility. LPA observed sufficient food supplies in the kitchen. Dining supervisor stated food supplies were ordered & delivered weekly. LPA observed dining area was expanded to allow for additional dining tables spaced 6 feet apart for residents’ use. LPA observed bathrooms have sufficient soap and paper towel supplies. LPA observed facility to be clean and in good repair. Sufficient staffing was observed during visit. LPA observed more than 30 days supply of PPEs, medication and incontinence supplies in several storage areas (basement, 1st and 2nd floors). Pathways and hallways were observed free of obstruction and fire hazards. Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/24/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Recruitment is ongoing which replaced 3 wait staff in dining roster who elected to go back to school. Facility is still recruiting 2 nurses, one CNA and one janitor. A new marketing assistant and social services manager were hired this month.

Residents’ council meeting on 09/13/21 reported that all successful bidders have expressed their intent to honor all residents’ contracts and those claiming refunds. ED shared a memorandum with LPA during visit regarding a non-binding sale transaction communicated to all residents on 09/22/2021. This tentative purchase and sale agreement of the facility is still subject to all necessary regulatory agency approvals before sale can be finalized and released by the bankruptcy court..

LPA observed residents comfortable, clean and well groomed. 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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2