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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601408
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:57:55 PM


Document Has Been Signed on 12/14/2023 02:57 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: 37DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Gaffar Syed, AdministratorTIME COMPLETED:
03:10 PM
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On 12/14/23 Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for 38.

LPA toured the facility including but not limited to bedrooms, bathrooms, activity room, kitchen and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 117.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 10/10/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 9/29/23.

LPA reviewed 5 residents records and 5 staff records, all were complete. LPA also reviewed a sample of resident’s medications.

During the visit LPA received an updated LIC610E Emergency and Disaster Plan and LIC9282 Infection Control Plan.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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