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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 06/30/2021
Date Signed: 06/30/2021 05:45:22 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: 144DATE:
06/30/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Mindy Han, AdministratorTIME COMPLETED:
05:55 PM
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On 6/30/21 at 3:50PM, Licensing Program Analysts (LPAs) G. Luk and L. Hall conducted an unannounced health and safety inspection. LPAs met with Administrator, Mindy Han and explained the purpose of the visit.

Upon entry, LPAs were screened at the front entrance with routine COVID-19 symptom checks done by the on duty staff. LPAs toured the facility with administrator. LPAs observed facility had sufficient food supplies in the kitchen and administrator stated that food supplies are ordered weekly. LPAs observed bathrooms has sufficient soap and paper towel supplies. LPAs obtained copies of menu, resident roster (assisted living), and dietary staff schedule. Sufficient staffing was observed during visit.

LPAs interviewed 5 residents during visit. LPAs observed that residents well groomed and resident apartments were clean.

LPAs requested documents (current employee roster, assisted living staff schedule, house keeping staff schedule, and maintenance staff schedule) to be submitted to LPAs by 7/1/2021.

No deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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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