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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601408
Report Date: 12/30/2021
Date Signed: 12/30/2021 01:33:16 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:LAKESHORE RESIDENTIAL CAREFACILITY NUMBER:
015601408
ADMINISTRATOR:SYED, GAFFARFACILITY TYPE:
740
ADDRESS:1901 THIRD AVENUETELEPHONE:
(510) 834-9880
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:38CENSUS: 36DATE:
12/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Gaffar Syed, AdministratorTIME COMPLETED:
01:45 PM
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On 12/30/20 Licensing Program Analyst (LPA) G. Clark and LPM Yvonne Flores-Larios arrived unannounced to conduct Infection Control Inspection. LPA and LPM met with Administrator, Gaffar Syed and explained the purpose of the visit.

During the Infection Control Inspection, LPA and Lpm toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Updated visitors policy will be posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. LPA and LPM advised that more signs should be throughout the facility. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Covered trash cans are needed in all shared bathrooms and beds need to be 6 feet apart. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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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