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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 01/03/2022
Date Signed: 01/03/2022 04:56:51 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: 120DATE:
01/03/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Tammy Hauck, Executive Director and Mindy Han, AdministratorTIME COMPLETED:
05:05 PM
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On 01/03/2022 at 03:40PM, Licensing Program Analyst (LPA) Laura Hall conducted an unannounced case management health & safety check and met with Mindy Han, Administrator and explained the purpose of the visit.

LPA was screened at the front entrance with routine COVID-19 symptom checks done by staff. LPA toured the facility with Administrator. LPA observed facility had sufficient food supplies in the kitchen. Food supplies are ordered & delivered weekly on Monday and Thursday. LPA also observed adequate supply of PPE in storage room located on the 2nd floor. 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.

Sufficient staffing was observed during visit. Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards. Comfortable temperature was maintained at 72 degrees Fahrenheit. LPA requested the following documents (current assisted living staff schedule, housekeeping staff schedule, and maintenance staff schedule) during visit to be emailed to CCLD by 1/5/2022.

Residents are updated by management of the latest Chapter 11 developments through monthly newsletters and residents’ council meeting notes. LPA attended the Resident's Council meeting today along with Executive Director. Executive Director stated Chapter 11 court has a new hearing on 1/10/2022 and the judge should declare an auction date. There were no other concerns during meeting.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
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: 01/03/2022
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Continued from LIC809.

The next Resident's Council meeting is scheduled on February 7, 2022 at 4PM. LPA requested minuets from Resident's Council meeting to be submitted to CCLD. 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 via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC809 (FAS) - (06/04)
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