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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 05/08/2025
Date Signed: 05/19/2025 10:48:11 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
05/01/2025 and conducted by Evaluator David Doidge
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250501153502
FACILITY NAME:LAKESIDE PARKFACILITY NUMBER:
019200529
ADMINISTRATOR:GRANT HAYWOODFACILITY TYPE:
740
ADDRESS:468 PERKINS STTELEPHONE:
(510) 444-4684
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:76CENSUS: 60DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jocelyn Fabros Resident Care DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not administer residents medication in a timely manner.
INVESTIGATION FINDINGS:
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On 05/08/2025 at 01:30PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver complaint findings for the allegation above. LPA met with Jocelyn Fabros Resident Care Director and explained the purpose of the visit.

During the investigation, LPA interviewed six (6) staff. LPA reviewed and obtained staff roster for Med Techs and Care Givers.

Resident Care Director shared more information on the delivery of medications. In interviews and Medication Administration Record (MAR) review. LPA observed that medications are being administered in a timely namnner. LPA confiermed in interviews, record review, and in MAR review that no resident has a specific doctor order mandating a specific time for medication to be administered. All residents that have medication orders for time frames, such as morning or evening.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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 2
Control Number 15-AS-20250501153502
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAKESIDE PARK
FACILITY NUMBER: 019200529
VISIT DATE: 05/08/2025
NARRATIVE
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Continued form LIC9099

Allegation: Staff do not administer residents medication in a timely manner

Finding: LPA observed in both interview and record review that although staff may administer medication at different times day-to-day, residents are still receiving medication in a reasonable time frame during each Med Tech shift. There is adequate overlap in the Med Tech schedules to ensure no resident goes with out medication and that all medications are delivered in a timely manner for each shift.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2