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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601408
Report Date: 03/15/2022
Date Signed: 03/15/2022 02:36:27 PM


Document Has Been Signed on 03/15/2022 02:36 PM - It Cannot Be Edited

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:
03/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Gaffar Syed, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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While at the facility to deliver findings on a complaint investigation, Licensing Program Analyst (LPA) Catherine Lin conducted a case management to address concerns noted while investigating on the facility’s handling of residents’ cash resources.

Deficiencies and plans of correction were discussed with Administrator, and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview was conducted and Appeal Rights was provided to Administrator.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/15/2022 02:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2022
Section Cited

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87216 Bonding
(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by;
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Based on records submitted by Administrator to LPA L. Fontanilla, facility is handling resident cash resources but does not have required surety bond issued by a surety company to the State of California as principal which is a potential risk to health and safety of residents under care.
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On 3/2/2022, Licensee has provided LPA L. Fontanilla a copy of facility’s surety bond in the amount of $50,000 issued by s surety company to the State of California. This deficiency is cleared
Type B
03/18/2022
Section Cited

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87216 Bonding
(d) No licensee shall either handle money of a resident or handle amounts greater than those stated in the affidavit submitted by him or for which his bond is on file without first notifying the licensing agency and filing a new or revised bond as required by the licensing agency.

This requirement is not met as evidenced by;
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Based on Affidavit Regarding Client/Resident Cash Resources (LIC400) signed by Administrator on 3/1/2022, the amount of money facility will handle for all residents has a maximum of $800.00 per month. A review of the expense logs submitted to LPA L. Fontanilla indicate facility is handling more than what is indicated in LIC400 which is a potential risk to the health and safety of residents under care.
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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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2