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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 10/03/2022
Date Signed: 10/03/2022 05:08:13 PM


Document Has Been Signed on 10/03/2022 05:08 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:LAKE PARKFACILITY NUMBER:
011400369
ADMINISTRATOR:JOHNSON OKEREFACILITY TYPE:
741
ADDRESS:1850 ALICETELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 106DATE:
10/03/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Tammy Hauck, Executive DirectorTIME COMPLETED:
05:20 PM
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On 10/3/22 at 3:35PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management health & safety check and met with Executive Director (ED). LPA explained the purpose of the visit with ED.

Upon entry, LPA was invited to join the resident council meeting, there were about 60 residents in the meeting. LPA observed that residents appeared peaceful and safe. LPA randomly interviewed 6 residents in the meeting, there were no imminent health/safety concerns on today's date.

LPA toured the facility with ED. Facility staff were observed wearing face masks, sufficient food supplies in the kitchen was observed. Food supplies are ordered & delivered weekly. LPA also observed adequate supply of PPEs in the cental storage on the 2nd floor, daily PPE supplies in each supervisor's office was observed and was easily accessible to staff. 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. ED stated the next resident council meeting is scheduled on November 7, 2022 at 3:30PM.

No deficiency cited during inspection. Exit interview conducted with ED and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
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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