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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 04/09/2021
Date Signed: 04/09/2021 10:48:32 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: 127DATE:
04/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mindy Han, AdministratorTIME COMPLETED:
10:48 AM
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On 04/09/21 at 9:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced Health & Safety inspection and met with administrator. LPA explained the reason of the visit with administrator. LPA obtained a copy of the latest personnel and residents rosters from administrator. LPA reviewed the daily census on the resident rosters which showed 18 residents in assisted living and 109 residents in independent living. Per administrator, there is sufficient staff working at the facility (i.e. approximately 24 staff in dining/dietary, 2 in maintenance, 8 in housekeeping, 10 in administrative, 4 in assisted living, 3 LVNs, 5 CNAs).

LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathrooms, activity rooms and common areas. During the health and safety check, LPA observed a total of 10 random staff members and 9 residents at the facility. LPA observed facility to be clean, sanitary and in good repair. LPA observed adequate lighting inside the facility. Sufficient perishable & non-perishable food, paper, water, PPEs and emergency supplies were available and observed in the kitchen and adjacent storage areas. LPA observed 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.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
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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