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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 07/09/2021
Date Signed: 07/09/2021 11:18:25 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:
07/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tammy Hauck, Executive DirectorTIME COMPLETED:
11:30 AM
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On 07/09/21 at 9:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health and safety inspection. LPA met with Executive Director and explained the purpose of the visit. LPA observed 8 staff wearing face masks during visit.

LPA was screened at the front entrance with routine COVID-19 symptom checks done by the on duty staff. LPA toured the facility with Executive Director. LPA observed facility to be clean and in good repair. Comfortable temperature was observed maintained at 75 degrees F. Executive Director stated that in a couple of weeks, delayed egress doors will be replaced and main dining area reconfigured for more communal dining seats available for residents' use. LPA observed sufficient food supplies in the kitchen and dining supervisor stated that food supplies were ordered & delivered weekly. LPA observed dining areas had round tables six feet apart with fresh cut flowers on top. LPA observed bathrooms has sufficient soap and paper towel supplies. LPAs obtained copies of menus, current resident roster (assisted living), and dietary staff schedule. Sufficient staffing was observed during visit. Pathways and hallways were observed free of obstruction and fire hazards.

LPA interviewed 5 residents during visit. LPA observed residents comfortable, clean and in good spirits. LPA obtained documents (current employee roster, assisted living staff schedule, house keeping staff schedule, and maintenance staff schedule) during visit. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during inspection. 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: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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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