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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 06/05/2025
Date Signed: 07/10/2025 04:03:29 PM

Unsubstantiated


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
05/28/2025 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20250528164448
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: 35DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Tibpets Madgu, Care StaffTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not prevent resident on resident assault
INVESTIGATION FINDINGS:
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This is an amended report. On 06/05/2025 at 2:10 PM, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit.

During the course of the investigation, LPAs interviewed S1, R1 and R2. LPA's also reviewed R1 and R2's facility files and the incident report dated 5/26/25.

LPA Interviewed R1 who stated that she was struck by R2 on 05/23/2025 at around 1 pm, while sitting around the patio area of the facility. R1 also stated that she did not know why R2 struck her and that she was just sitting on the patio talking on her cellphone.

***CONTINUE ON 9099C***

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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 2
Control Number 15-AS-20250528164448
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: 06/05/2025
NARRATIVE
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***CONTINUE FROM 9099**

LPAs interviewed R2 who stated that did not hit R1 and that he never hits anyone stating "I don't want to get in trouble." R2 stated that he approached R1 and asked her to quiet down or leave the patio as he was " trying to meditate".

LPAs interviewed S1 who stated that on 5/23/25 R1 was observed sitting in the patio area talking very loudly on her cellphone when another resident (R2) and asked R1 to quiet down. R1 then yelled out that R2 had hit her and then R1 called Oakland Police Department (OPD). S1 did not see R2 hit R1. S1 further stated that OPD arrived, interviewed both parties and issued citations to each of them. S1 also stated that R1 called 911 and went to the hospital to be checked out.

LPAs reviewed the discharge papers from the hospital visit that documented there was no injuries to R1's face.

During the course of the visit LPAs observed the facility residents to be quiet and respectful to each other space. S1 stated the facility is very mindful of not accepting residents who have a history of aggressive behavior as many of the residents in the facility are very vulnerable.

On 7/10/25 LPA asked R1 about another incident that allegedly happened on 4/27/25 when R1 was allegedly attacked by R3. R1 could not recall the incident and didn't want to about it anymore. S1 said he did not recall any incident between R1 and R3 and that R3's room is on the opposite side of the facility from R1's room and it's not likely that the two had any interaction.

This agency has investigated the complaint alleging staff did not prevent resident on resident assault. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2