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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:54:02 AM


Document Has Been Signed on 11/17/2022 11:54 AM - 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: 117DATE:
11/17/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Tammy Hauck, Executive DirectorTIME COMPLETED:
12:05 PM
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On 11/17/2022 at 11:15AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management health & safety check and met with Tammy Hauck, Executive Director (ED), 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 ED. LPA observed facility had sufficient food supplies in the kitchen. LPA also observed adequate supply of PPEs in the cental storage on the 2nd. Cough/sneeze etiquette and hand washing posters were observed posted in common areas and bathrooms. LPA observed dining area has been expanded to give additional seating choices for residents with tables six feet apart for social distancing, and varieties of warm food were served as lunch.

Sufficient staffing was observed during visit. Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards. LPA obtained LIC 500 during visit, and requested the following documents (current assisted living staff schedule, nursing schedule, housekeeping staff schedule, maintenance staff schedule, and food service schedule) submit to CCL today.

There was no imminent health/safety concerns on today's date.

Exit interview conducted with ED and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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