019200529-3-17-2025-15-AS-YFLS-DEVPK7-20250318112241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 03/17/2025
Date Signed: 03/17/2025 02:28:44 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
07/24/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240724123118

FACILITY NAME:	LAKESIDE PARK		FACILITY NUMBER:	019200529
ADMINISTRATOR:	ESPINOZA, CHELSEA J		FACILITY TYPE:	740
ADDRESS:	468 PERKINS ST		TELEPHONE:	(510) 444-4684
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	76	CENSUS: 63	DATE:	03/17/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Grant Haywood, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Questionable death
Staff did not properly change resident resulting in resident developing a UTI and Sepsis while in care.

INVESTIGATION FINDINGS:

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On 3/17/25 at 2:00 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver findings for the above allegations. LPA met with Grant Haywood, Executive Director and explained the purpose of the visit.

During the course of investigation, the Department interviewed W1, 5 facility staff and 3 facility residents. The Department also reviewed R1’s medical records, copy of Oakland Police report, and R1’s death certificate. Review of documents revealed that R1 was admitted to the facility on 1/29/24 with a diagnosis of Alzheimer’s Disease. R1 was non-ambulatory at the time of admission.

Allegations: Questionable death
Staff did not properly change resident resulting in resident developing a UTI and Sepsis while in care.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20240724123118

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: 03/17/2025

NARRATIVE

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***report continues from LIC9099***

The Department interviewed W1. W1 stated R1 was in the facility for approximately 5 months. W1 stated that R1 had “full on Alzheimer’s.” W1 further stated that she was aware that on 6/17/24, R1 was admitted to the hospital. W1 was unsure on the reason of the hospital visit. W1 stated R1 had cancer, but the “cancer wasn’t killing him, it just weakened him.” W1 also stated that after the hospital visit, R1 was placed on hospice and then died about two days later. W1 claimed that the facility staff weren’t keeping R1 hydrated by allowing him to drink only soda and that they left him in dirty diapers causing R1 to get a UTI and sepsis.

The Department interviewed S1. S1 stated that R1 had a steady decline in health while at the facility with multiple falls regardless of staff intervention and alarms that were put in place. R1 liked to be independent and would get out of bed on his own. S1 also stated that there was a problem with keeping R1 hydrated as he preferred to only drink Coca Cola however the facility offered water and juices to R1 as well.

Interviews with the other facility staff (S2, S3, S4 and S5) all revealed the same information; that R1 was in a steady decline of health during his time at the facility, that R1 refused to drink water or juice preferring Coca Cola. Per staff, R1 sustained several falls even with staff intervention and bed alarms that were put in place. R1 had multiple falls due to R1 thinking R1 was independent and capable of transferring himself out of bed in order to get to the bathroom. R1 did sustain multiple urinary tract infections (UTI) R1 did wear diapers but was always cleaned in a timely manner. No staff reported that R1 ever had an issue with being dirty or sitting in a dirty diaper for prolonged periods of time.

Staff were all trained to change residents as soon as they observed that the diaper was soiled.

On 6/16/24, R1 sustained an unwitnessed fall. R1 was evaluated by S5. S5 assessed the resident with no injuries, R1 had no complaints of pain, and vitals were normal. R1 remained at the facility and S5 monitored him for any change to baseline. R1 was sent to the hospital for an evaluation after S3 noticed R1 was not acting like himself. At the hospital R1 was diagnosed with “Sepsis without acute organ dysfunction, due to unspecified organism.”

***report continues on LIC9099C***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 15-AS-20240724123118

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: 03/17/2025

NARRATIVE

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***report continues from LIC9099C***

Review of R1’s Certificate of Death from the County of Alameda states that R1 died on 6/25/24. Immediate cause of death was listed as to Sepsis, Metastatic Prostate Cancer, and Dementia. Secondary Cause of death was listed as, Diabetes Mellitus Hypertension.

The Department has investigated the complaint alleging questionable death and staff did not properly change resident resulting in resident developing a UTI and Sepsis while in care. The Department has found that the allegations above are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025

LIC9099 (FAS) - (06/04)

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