015601408-3-15-2022-15-AS-KHOS-CCRLJX-20220322084839

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 03/15/2022
Date Signed: 03/15/2022 02:33:40 PM

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
04/16/2021 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210416135822

FACILITY NAME:	LAKESHORE RESIDENTIAL CARE		FACILITY NUMBER:	015601408
ADMINISTRATOR:	SYED, GAFFAR		FACILITY TYPE:	740
ADDRESS:	1901 THIRD AVENUE		TELEPHONE:	(510) 834-9880
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94606
CAPACITY:	38	CENSUS: 36	DATE:	03/15/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Gaffar Syed, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff is not feeding resident.
Resident is without toiletries.
Staff requesting money from resident.

INVESTIGATION FINDINGS:

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On 3/15/22 approximately at 1:00pm, Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to deliver findings for the above allegations. LPA met with Administrator Gaffar Syed and explained the purpose of visit.

On 4/20/2021, LPA Luisa Fontanilla initiated 10-day investigation, interviewed Administrator, 2 staff and Resident 1 (R1) and obtained records.

Allegation: Staff is not feeding resident.
On 4/20/2021, LPA interviewed R1 and 2 staff. R1 states facility provides enough food and can get second serving, if requested. Staff interviewed state that R1 is independent with eating and was observed to have a good appetite. A review of R1’s Individual Services Plan (ISP) and Physician’s Report indicate that R1 is able to feed self. This allegation is unsubstantiated.
(Continue LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210416135822

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: 03/15/2022

NARRATIVE

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Allegation: Resident is without toiletries.
During the interview, R1 states that facility provides soap, shampoo, toilet paper and other hygiene products. Administrator and staff state that the facility provides all residents with hygiene products and toiletries all the time. This allegation is unsubstantiated.

Allegation: Staff requesting money from resident.
LPA L. Fontanilla interviewed R1 on 4/20/21. During the interview, LPA asked R1 if there is a staff asking money from R1. R1 states there is a staff who asks money but R1 does not know the name because staff use fake name. Administrator states that facility is handling R1’s money as requested by R1. Administrator added that facility maintains a log for R1’s expenses. Administrator provided LPA a copy of R1’s expenses log.
Staff interviewed denied knowing any staff asking money from R1 or any other resident.
This allegation is unsubstantiated.

Based on interviews and records review conducted, the allegations are UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there are not a preponderance of the evidence to prove that violations occurred.

Exit interview was conducted and copy of this report provided to Administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
04/16/2021 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210416135822

FACILITY NAME:	LAKESHORE RESIDENTIAL CARE		FACILITY NUMBER:	015601408
ADMINISTRATOR:	SYED, GAFFAR		FACILITY TYPE:	740
ADDRESS:	1901 THIRD AVENUE		TELEPHONE:	(510) 834-9880
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94606
CAPACITY:	38	CENSUS: 36	DATE:	03/15/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Gaffar Syed, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident's hygiene needs are not being met.

INVESTIGATION FINDINGS:

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LPA Luisa Fontanilla interviewed R1 and 2 staff on 4/20/2021. LPA also reviewed shower log for April 2021, R1’s Individual Services Plan (ISP) and Physician’s Report. Based on interview with staff, R1 gets help with shower 2-3 times a week and sometimes more if R1 requests. When interviewed by LPA, R1 confirmed that staff assist with showers 2-3 times a week. A review of R1’s shower log indicate R1 gets shower 2 times per week as indicated in R1’s individual service plan.

Based on interviews and records review conducted, the allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview was conducted and copy of this report provided to Administrator.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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