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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 10/29/2021
Date Signed: 10/29/2021 10:14:17 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: 151DATE:
10/29/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Annmarie Charles, Director of NursingTIME COMPLETED:
10:15 AM
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On 10/29/21 at 09:35 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management health & safety check and met with the Director of Nursing (DON). LPA explained the purpose of the visit with DON and administrator on the phone who authorized DON to act on her behalf and sign the reports.

LPA was screened at the front entrance with routine COVID-19 symptom checks done by staff. LPA toured the facility with DON. LPA observed facility had sufficient food supplies in the kitchen. Food supplies are ordered & delivered weekly. LPA also observed adequate supply of PPEs in several storage areas. LPA observed bathrooms has sufficient soap and paper towel supplies. LPA observed dining area has been expanded to give additional seating choices for residents with tables six feet apart for social distancing. Comfortable temperature was maintained at 73 degrees Fahrenheit.

Sufficient staffing was observed during visit. Pathways and hallways were observed free of obstruction and fire hazards. LPA observed residents clean, well-groomed and comfortable in their apartments. Residents are updated by management of the latest Chapter 11 developments through monthly newsletters and residents’ council meeting notes. The next residents' council meeting is scheduled on 11/01/21. LPA obtained documents (current employee roster, assisted living staff schedule, housekeeping staff schedule, and maintenance staff schedule) during visit.

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: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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