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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 07/08/2025
Date Signed: 07/08/2025 01:00:38 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
06/23/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250623104119
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: 61DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Grant Haywood, Executive DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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9
Facility did not provide supervision to residents in care.
INVESTIGATION FINDINGS:
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On 07/08/2025 at 09:40 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the allegation above. LPAs met with Grant Haywood, Executive Director (ED) and explained the purpose of the visit.

During the investigation, LPAs interviewed five (5) staff. LPAs reviewed and obtained copies of Physician’s reports (602), Appraisal Needs and Services (ANS), Physician Communication Form, Preplacement Appraisal and Medication lists for AP and AV

Allegation: Facility did not provide supervision to residents in care.

Investigation Finding: Leading up to the event S1 was assisting a resident in the common area, S2 was in another resident’s room. and S3 was on break. No staff directly witnesses the event. Staff did, however, responded immediately after hearing it start. Staff acted appropriately and quickly. Staff were able to redirect AP and assist AV. AP has verbal aphasia, and a history of dementia. Based on interviews with staff, there was sufficient staff present.

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

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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-20250623104119
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: 07/08/2025
NARRATIVE
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Continued from LIC9099

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this 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: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2