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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 10/04/2022
Date Signed: 10/04/2022 03:47:27 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
08/31/2022 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20220831130807
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:
10/04/2022
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Gaffar Syed, AdministratorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff do not monitor resident for change in condition
INVESTIGATION FINDINGS:
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On 10/4/22 at 2:35 p.m., Licensing Program Analyst (LPA) G. Clark conducted an unannounced visit to continue the investigation for the above allegation. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit..

During the course of investigation, LPA interviewed the reporting party, the facility administrator and 2 residents: R1 and R2. LPA also reviewed R1's facility file. Interviews and documents reviewed demonstrate that the facility does have a process in place to monitor residents for changes in condition. The is no documentation showing any change of condition for the residents involved.

Based on LPA's interviews conducted and files reviewed the allegation is UNSUBSTANTIATED.

***report cont'd on LIC9099C***
Unsubstantiated
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: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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-20220831130807
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: 10/04/2022
NARRATIVE
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***report continues from LIC9099***

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 reported provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2