019200529-5-20-2025-15-AS-KHOS-DH2VRE-20250526163948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 05/20/2025
Date Signed: 05/20/2025 12:27:18 PM

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
05/12/2025 and conducted by Evaluator David Doidge

COMPLAINT CONTROL NUMBER: 15-AS-20250512120135

FACILITY NAME:	LAKESIDE PARK		FACILITY NUMBER:	019200529
ADMINISTRATOR:	GRANT HAYWOOD		FACILITY TYPE:	740
ADDRESS:	468 PERKINS ST		TELEPHONE:	(510) 444-4684
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	76	CENSUS: 62	DATE:	05/20/2025
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Grant Haywood, Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not adhere to resident's admission agreement
Staff threatened resident in care
Staff did not properly follow resident's medical orders

INVESTIGATION FINDINGS:

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On 05/20/2025 at 11:20AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the allegations above. LPA met with Grant Haywood, Executive Director (ED).

During the investigation, LPA interviewed two (2) staff. LPA reviewed and obtained copies of Admission Agreement and the, Physician’s report (602), for R1 and the facility's activity calender.

Allegation: Staff did not adhere to resident's admission agreement

Investigation Finding: LPA review resident’s Admission Agreement and spoke with ED regarding room and rental space. R1 and RP had a verbal agreement with Lakeside that allowed R1 to use an unrented space in a double room for storing items that did not fit in R1’s room. This is not part of the Admission Agreement, and the facility has the right to ask a resident to remove items from a space that is not being rented to a resident. The allegation is therefore unsubstantiated.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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-20250512120135

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: 05/20/2025

NARRATIVE

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Continued from LIC9099

Allegation: Staff threatened resident in care

Investigation Finding: LPA spoke with S1 and S2 and confirmed that the facility has the right to charge residents for use of space that is not part of the original agreed upon rental space.This is also confirmed in the Admission Agreement. Therefore this allegation is unsubstantiated.

Allegation: Staff did not properly follow resident's medical orders

Investigation Finding: LPA interviewed S1 and S2 who both confirmed that residents have a daily walking activity, weather permitting, and other activities that take residents outside. LPA reviewed the activities calendar confirming multiple outdoor activities are available. R1's 602 does not specify that R1 needs to be taken outside or for daily walks. This allegation is therefore unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are 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: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC9099 (FAS) - (06/04)

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