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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 06/21/2021
Date Signed: 06/21/2021 11:09:05 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: 147DATE:
06/21/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mindy Han, AdministratorTIME COMPLETED:
11:30 AM
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On 06/21/21 at 10 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced Health & Safety inspection and met with administrator. LPA explained the reason of the visit with administrator. LPA obtained a copy of the latest personnel and residents rosters from administrator. LPA observed staff wearing face masks at the facility. LPA reviewed the daily census on the resident rosters which showed 18 residents in assisted living and 129 residents in independent living. Per administrator, there is sufficient staff working at the facility (i.e. approximately 24 staff in dining/dietary, 2 in maintenance, 8 in housekeeping, 10 in administrative, 4 in assisted living, 3 LVNs, 5 CNAs). Total staff is 80 full time workers and 30 on-call/part timers. LPA observed 3 staff at the front entrance, 7 staff in the dining area and 4 staff in assisted living during visit.

LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathrooms, activity rooms and common areas. LPA observed facility to be clean, sanitary and in good repair. LPA observed sufficient perishable & non-perishable food, paper, water, PPEs and emergency supplies were available and stored in the kitchen and adjacent storage areas. LPA observed 5 female residents in their assisted living apartments enjoying the nice weather and clean surroundings. LPA observed them to be well groomed, clean and happy. LPA observed residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies were observed during the health and safety check.
Exit interview conducted and a copy of this report provided to administrator.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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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