019200529-5-17-2024-15-AS-YFLS-D64W4X-20240610165816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 05/17/2024
Date Signed: 05/17/2024 12:17:08 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
10/20/2023 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20231020144049

FACILITY NAME:	LAKESIDE PARK		FACILITY NUMBER:	019200529
ADMINISTRATOR:	JULIE PETERSON		FACILITY TYPE:	740
ADDRESS:	468 PERKINS ST		TELEPHONE:	(510) 444-4684
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	76	CENSUS: 52	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Grant Haywood, Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Lack of supervision resulting in questionable death

INVESTIGATION FINDINGS:

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On this day at around 11:00 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding on the above allegation and met with Executive Director Grant Haywood. LPA explained to Haywood the purpose of the visit.

During the course of investigation, LPA conducted 10-day initial visit and obtained the following records on 10/24/2023: Resident 1 (R1) Physician’s Report, Incident Report, Death Report, Resident Roster, Staff Roster, Point Click Care, Sheriff Contact information and Preplacement Appraisal. The complaint was referred to the Investigations Branch (IB) on 10/20/2023 and was accepted as an assignment.

Based on record reviews conducted, R1’s Physician’s Report indicates R1 has Dementia, is on diabetic diet and is able to feed self. R1’s PointClickCare record indicates for staff to remind and encourage R1 to attend meals.
continuation on Lic 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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-20231020144049

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: 05/17/2024

NARRATIVE

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continuation from Lic 9099

R1’s preplacement appraisal indicates R1 is diabetic but does not need help with eating.

Incident report submitted to CCL states that the Medication Technician (MT) observed R1 going to the bathroom, followed R1 to assist at around 5:05 pm on 10/15/2023. When the MT observed R1 looking pale, MT called a caregiver to assist. R1 passed out, staff then called 911 and performed CPR.

The Department’s investigation concludes that there was no indication of lack of supervision. Staff were present and obtained immediate medical care. Autopsy was performed on R1 to determine the cause of death.

R1’s death certificate recorded Asphyxia, choking on food bolus as the cause of death, manner of death as accident and time of death is 1705 hours. Autopsy was performed on R1 to determine the cause of death.

Based on record reviews conducted, the above allegation is 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.

There is no deficiency noted for this visit.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

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