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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400369
Report Date: 07/19/2021
Date Signed: 07/19/2021 01:52:24 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:
07/19/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Mindy Han, AdministratorTIME COMPLETED:
02:00 PM
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On 07/19/21 at 11:57AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health and safety inspection. LPA met with administrator and explained the purpose of the visit. LPA was screened at the front entrance with routine COVID-19 symptom checks done by the on duty staff wearing face masks. LPA observed COVID-19 signages posted in common areas as reminders for staff and residents to wear face masks, practice proper cough/sneezing etiquette, frequent hand sanitizing/hand washing, social distancing, etc. LPA received updated resident roster, assisted living staff schedule, house keeping staff schedule, and maintenance staff schedule, dietary menus from administrator during visit.

LPA toured the facility with administrator. Comfortable temperature was observed maintained at 75 degrees F. LPA observed adequate lighting at the facility. 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 have sufficient soap and paper towel supplies. LPA observed facility to be clean and in good repair. Sufficient staffing was observed during visit. LPA observed more than 30 days supply of PPEs, medication and incontinence supplies in several storage areas (basement, 1st and 2nd floors). Pathways and hallways were observed free of obstruction and fire hazards.

LPA interviewed 5 residents during visit. LPA observed residents comfortable, clean and well groomed. 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: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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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