015601408-6-19-2024-15-AS-KHOS-D9MP89-20241001110511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 06/19/2024
Date Signed: 06/19/2024 12:26:12 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
06/11/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240611093513

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:	06/19/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Gaffar Syed, Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff do not ensure a safe environment is provided for residents.

INVESTIGATION FINDINGS:

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On 6/19/24 at 10:00 a.m., Licensing Program Analysts (LPAs) Greg Clark and A. Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit.

During the investigation LPAs reviewed R1's facility file and interviewed S1 S2, and 2 residents (R2, R3).

R1 was admitted to the facility on 5/16/24. Pre-appraisal documents state that R1 can become confused, anxious and agitated at times. On 6/1/24 while staff (S2) was attempting to administer R1 his PM medications he became very agitated and combative with S2. R1 hit the S2 on the face but there was no serious injury. 911 was called and R1 was transported to John George Psychiatric Hospital. R1 returned to the facility the following day.

***report continues on LIC9009C***

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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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-20240611093513

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: 06/19/2024

NARRATIVE

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***report continues from LIC9099***

On 6/10/24 R1 became argumentative with another resident (R3) wanting to take her snack. Staff intervened and R1 was redirected. However, another resident (R2) called 911, police arrived and R1 was taken to Summit Hospital and subsequently transferred to John George Psychiatric Hospital where he remains as of today. Doctors at John George are adjusting R1’s medications to lessen his anxiety and combativeness.

S1 stated that the residents at the facility were never in any danger due to R1’s behaviors and that staff took appropriate action to redirect R1 to ensure the safety of the other residents.

LPAs interviewed R2. R2 stated that she feared for the safety of the other residents and was unaware that staff were redirecting R1 to unsure the safety of the other residents. R2 also stated that she felt R1 was a “bad person” and should be living at the facility.

LPAs interviewed R3. R3 stated that she was “very happy” living at the facility and that she has several friends whom she likes to socialize with. LPAs asked R3 about the incident involving R1 but R3 could not recall the incident. R3 also stated that she felt safe living at the facility.

LPAs also interviewed S2. S2 stated that while attempting to give R1 his PM medications (S2 couldn’t recall the date) R1 grabbed the medications from her and threw them on the floor. He also grabbed the water cup and threw that as well. R1 also scratched S2 on her face. S2 declined medical attention. S2 also stated that feels “very safe” working at the facility.

This agency has investigated the complaint alleging staff do not ensure a safe environment is provided for residents. 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: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

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