015601408-2-14-2024-15-AS-YFLS-D35TY5-20240307140806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:43:49 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
12/18/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20231218150828

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: 37	DATE:	02/14/2024
		UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Gaffar Syed, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not allow resident back to the facility

INVESTIGATION FINDINGS:

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On 2/14/24 at 3:10 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver finding 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 LPA interviewed the reporting party (RP), S1 and reviewed R1’s file including Unusual Incident Reports (UIRs).

R1 was admitted to the facility on 6/25/22. On 11/17/23 R1 was transferred to Summit Hospital after a fall. While at the hospital R1 was diagnosed with c-diff. Summit Hospital discharged R1 to a rehabilitation facility on 11/23/23. On 12/06/23 facility staff went to visit R1 at the rehab facility. R1 was in isolation due to the c-diff. At that time, it was determined that R1 needed a high level of care ie: skilled nursing facility.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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-20231218150828

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: 02/14/2024

NARRATIVE

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***Report continues from LIC9099***

The RP stated that she asked the facility to take R1 back until a SNF placement could be found. S1 told the RP that they could not take R1 back because her level of care is outside the scope of their license.

This agency has investigated the complaint alleging staff did not allow resident back to the facility. 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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC9099 (FAS) - (06/04)

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