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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 07/05/2024
Date Signed: 07/05/2024 12:24:17 PM

Unfounded


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
06/25/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240625163122
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: 37DATE:
07/05/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gaffar Syed, AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not administer resident's medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/05/2024 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit.

During the course of the investigation LPA interviewed the R1 and S1 and reviewed RP’s doctor’s orders.

Allegation: Staff do not administer resident's medications.
LPA reviewed a doctor’s order dated 6/28/24 addressed to the R1. The order states that the R1 “is able to manage their own medications when medications are presented to her in a Medication Blister Packs.”

This agency has investigated the complaint alleging staff do not administer resident's medications. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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