019200529-4-18-2022-15-AS-KHOS-CE5JTN-20220505072014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 04/18/2022
Date Signed: 04/18/2022 03:26:06 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
07/28/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200728105241

FACILITY NAME:	LAKESIDE PARK		FACILITY NUMBER:	019200529
ADMINISTRATOR:	WILLIAMS, RICHARD		FACILITY TYPE:	740
ADDRESS:	468 PERKINS ST		TELEPHONE:	(510) 444-4684
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	76	CENSUS: 26	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Julie Peterson, Executive Director		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Insufficient staffing to meet residents' needs.

Facility not maintained clean and sanitary.

Staff did not prepare food to meet residents' needs.

Staff did not answer communication with responsible party promptly

INVESTIGATION FINDINGS:

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On 4/18/2022 at 2:15PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. LPA met with Julie Peterson, Executive Director (ED) and explained the reason for the visit.

During the investigation LPA. P. Singh interviewed staff. LPA L. Hall interviewed staff on today's date. LPA was not able to interview residents due to their diagnosis. On the allegation insufficient staff to meet residents needs. LPA observed staffing schedule for July 2020. Facility had sufficient staffing for all three (3) shifts, including med techs and kitchen crew. LPA also observed three (3) staff dancing with the residents.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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-20200728105241

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: LAKESIDE PARK	FACILITY NUMBER: 019200529
	VISIT DATE: 04/18/2022

NARRATIVE

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Continued from LIC9099.

Based on the allegation facility not maintained clean and sanitary. During interview S1 and S2 stated that due to COVID rooms are cleaned once a week, high-touch areas 4 (four) times a day, shared restrooms two (2) times a shift. LPA L. Hall toured facility with ED during today's visit and observed facility to be clean and sanitary. During tour LPA observed staff sanitizing high touched surfaces. ED stated that surfaces are sanitized three (3) times a day.

Based on the allegation staff did not prepare food to meet residents needs. LPA toured kitchen on today's visit and observed a sufficient amount foods. LPA obtained menu for a week which had a variety of foods. ED stated food delivers occur every Tuesday and Thursday.

Based on the allegation staff did not answer communication with responsible party promptly. LPA P. Singh telephoned the facility four (4) times, and three (3) of the four (4) times the telephone was answered immediately. The one time the telephone rang 3 times then went to voicemail. LPA L. Hall interviewed S5 during visit. S5 stated that residents communicate with their families through telephones located on the floor, FaceTime, Zoom, and Skype. After 6pm phones are transferred to the med tech cell phone. If phones go into voicemail S5 will return call ASAP if necessary or forward message to the appropriate party.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

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