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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 01/20/2022
Date Signed: 01/20/2022 03:50:25 PM


Document Has Been Signed on 01/20/2022 03:50 PM - It Cannot Be Edited

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: 119DATE:
01/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Mindy Han, AdministratorTIME COMPLETED:
04:05 PM
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On 01/13/2022 at 02:20PM, Licensing Program Analysts (LPAs) Laura Hall, Kelly Nguyen, and Liridon Fici conducted an unannounced case management health & safety check and met with Mindy Han, Administrator and explained the purpose of the visit.

LPAs were screened at the front entrance with routine COVID-19 symptom checks done by staff. LPAs toured the facility with Administrator. LPAs observed facility had sufficient food supplies in the kitchen. Food supplies are ordered & delivered weekly on Monday and Thursday. LPAs also observed adequate supply of PPE in storage room located on the 2nd floor. LPAs observed bathrooms has sufficient soap and paper towel supplies. LPAs 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 1/24/2022.

Residents are updated by management of the latest Chapter 11 developments through monthly newsletters and residents’ council meeting notes. No updates reported for Chapter 11. The next Resident's Council meeting is scheduled on February 7, 2022 at 4PM. 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: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2022
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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