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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 04/30/2025
Date Signed: 04/30/2025 02:45:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220209145931
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:
04/30/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Gaffar Syed/AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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-Staff did not seek medical attention for resident (R1) in a timely manner.

-Facility has pests.
INVESTIGATION FINDINGS:
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On this day, April 30, 2025, at 1:15 pm, Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Gaffar Syed, administrator (ADM), and informed the reason for visit.

During the course of investigation, the Department obtained copies of staff schedule, resident roster and the following residents' documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Unusual Incident Report (UIR); hospital After Visit Summary. LPA interviewed the following: residents (R1, R2, R3) on 2/16/22; staff (S1, S2 and S3) on 2/16/22 and 4/30/25; witness (W1) on 4/29/25; R4 on 4/30/25; ADM on 4/30/25. LPA conducted inspection on 2/16/22.

.....continued 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20220209145931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAKESHORE RESIDENTIAL CARE
FACILITY NUMBER: 015601408
VISIT DATE: 04/30/2025
NARRATIVE
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Allegation: Staff did not seek medical attention for resident (R1) in a timely manner.
The reporting party stated that R1 sustained laceration to the forehead, and it was still bleeding when Emergency Medical Team (EMT) arrived. RP further stated that R1 had fallen at 8:30am and the facility was delayed in seeking medical attention when R1 had bleeding.

W1 stated that W1 came to the facility in the afternoon to attend to R1 who was bleeding when W1 arrived. W1 had to wrap R1’s head to control the bleeding. W1 further stated that the facility called the ambulance when it should be 9-11 that they should call, because R1 fell and was bleeding. LPA reviewed R1’s UIR which showed R1 fell at 8:15 am, was bleeding in the forehead and first aid performed. UIR also confirmed W1’s statement that ambulance was called at 3:00 pm. When LPA interviewed R1, R1 verbalized he was in pain.

Based on interviews and records review, the allegation is substantiated.

Allegation: Facility has pests.
Two out of 3 staff and 2 out of 3 residents interviewed stated observing cockroaches. W1 also stated observing cockroaches in R1’s room. Therefore, the allegation is substantiated.

Based on interviews which were conducted, the preponderance of evidence has been met, therefore the above allegations are substantiated. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with ADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220209145931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKESHORE RESIDENTIAL CARE
FACILITY NUMBER: 015601408
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2025
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening........
-This requirement is not met as evidenced by:
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Administrator to in-service the staff and submit copy of training topics with attendees signatures by 5/01/25.
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-Based on interviews and records review, the licensee did not comply with the section when R1 fell and sustained injury and staff did not call 9-1-1 immediately which posed an immediate health, safety and personal rights risks to person in care.
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Type B
05/14/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Corrected.
Administrator contracted with pest control company to eradicate the pest problems.
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-This requirement is not met as evidenced by:
-Based on interviews, the licensee did not comply with the section above in facility having cockroaches.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220209145931

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:
04/30/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Gaffar Syed/AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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-Resident (R1) had an incident while in care.

-Resident (R1) sustained injury while in care.

INVESTIGATION FINDINGS:
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On this day, April 30, 2025, at 1:15 pm, Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to continue the investigation of the above allegations and close the complaint. LPA met with Gaffar Syed, administrator (ADM), and informed the reason for visit.

During the course of investigation, the Department obtained copies of staff schedule and the following residents' documents: LIC601 Identification and Emergency Contact Information; LIC602 Physician's Report; Unusual Incident Report (UIR); hospital After Visit Summary. LPA interviewed the following: residents (R2, R3) on 2/16/22; staff (S1, S2 and S3) on 2/16/22 and 4/30/25; witness (W1) on 4/29/25; R4 on 4/30/25; ADM on 4/30/25. LPA interviewed R1 on 2/16/22.

....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220209145931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAKESHORE RESIDENTIAL CARE
FACILITY NUMBER: 015601408
VISIT DATE: 04/30/2025
NARRATIVE
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Allegation: Resident (R1) had an incident while in care.
Allegation: Resident (R1) sustained injury while in care.

LPA interviewed R1 who was able to verbalized he was pain but unable to provide other information. R2, R3, R4 stated staff are okay. One of the staff interviewed stated not observing other staff being abusive or hurt any of the residents.

Review of UIR showed R1 fell on 2/08/22 at the kitchen door in the hallway and sustained injury in the forehead. One of the 3 staff interviewed stated R1 fell near the kitchen. Review of R1’s LIC602A showed that although R1 has dementia but ambulatory. LIC625 did not indicate R1 needed assistance in ambulation.

Based on interviews and record review and LPA unable to obtain information from R1 about the incident, the allegations are unsubstantiated. An unsubstantiated findings means that although the allegations may have happened or are valid, the preponderance of evidence standard has not been met.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5