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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:38:28 PM

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:
06/23/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mindy Han, AdministratorTIME COMPLETED:
04:55 PM
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On 06/23/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health and safety check and met with administrator. LPA explained the purpose of the visit with administrator.

LPA observed 6 staff wearing masks during visit. A universal entry screening station was observed at the front entrance with routine COVID-19 symptom checks done by the on duty security guard and visitor's log with COVID-19 symptom questions completed by residents, staff and visitors. LPA toured the facility with administrator. LPA observed sufficient food supplies in the kitchen and a farmer's market station had fresh fruits and dessert available. LPA observed a live jazz band playing at the reception area where more than 15 residents were observed seated enjoying the music. LPA received copies of facility's personnel record, resident roster, weekly menus for breakfast, lunch and dinner and staff rosters for various departments. Food deliveries are received from Freshpoint daily, Luz American & Sysco twice a week and Nestle weekly as stated by dining supervisor. Facility was observed to be clean, sanitized and in good repair. Comfortable temperature was maintained at 75 degrees F. Sufficient staffing was observed during visit.

LPA interviewed 10 residents (3 in Assisted Living and 7 in Independent Living) during visit. Residents were observed to be well groomed, relaxed and comfortable in their surroundings. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

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

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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