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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 08/15/2022
Date Signed: 08/15/2022 02:14:19 PM


Document Has Been Signed on 08/15/2022 02:14 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: 109DATE:
08/15/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Johnson Okere, AdministratorTIME COMPLETED:
02:30 PM
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On 08/15/22 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management health & safety check and met with administrator. LPA explained the purpose of the visit with administrator.

LPA was screened at the front entrance with routine COVID-19 symptom checks done by staff. LPA toured the facility with administrator. Facility staff were observed wearing N95 face masks. 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 (first, second floors and basement). LPA observed bathrooms has sufficient soap and paper towel supplies.Cough/sneeze etiquette and hand washing posters were observed posted in common areas and bathrooms.

Sufficient staffing was observed during visit. Pathways and hallways were observed free of obstruction and fire hazards. Comfortable temperature was maintained at 72 degrees Fahrenheit. Administrator stated the next resident council meeting is scheduled on September 12, 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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