019200529-10-24-2025-15-AS-BFOG-DN5TV7-20251105140329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 10/24/2025
Date Signed: 10/24/2025 03:06:10 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
10/17/2025 and conducted by Evaluator David Doidge

COMPLAINT CONTROL NUMBER: 15-AS-20251017125819

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: 58	DATE:	10/24/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director Grant Haywood		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not administer medication to a resident in care.

INVESTIGATION FINDINGS:

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On 10/24/2025 at 09:00 AM, Licensing Program Analyst (LPA) David Doidge Licensing Program Manager (LPM) Jeremy Fong arrived at the facility unannounced to conduct an initial 10-day complaint investigation and deliver findings in regards to the allegation above. Upon arrival, LPA and LPM met Executive Director Grant Haywood with and explained the purpose of the visit.

During the investigation, LPA and LPM interviewed S1. LPA rand LPM reviewed and obtained copies of Physician’s reports (602), Medication lists, and the Electronic Medication Administration Records (eMAR) for four R1 - R4residents.

Allegation: Staff did not administer medication to a resident in care.

Investigation Findings: It was reported to the department that the facility was not administering medication to a resident in care. LPA and LPM obtained a copy of the current resident roster. From the roster LPA and LPM selected four (4) residents records to review.

Continue don LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025

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-20251017125819

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: 10/24/2025

NARRATIVE

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Continued from LIC9099

LPA and LPM reviewed the medication list and eMAR for R1, R2, R3 and R4 with S1. eMAR showed that over the course of three months no medication doses were missed. S1 informed LPA and LPM of medication distribution procedures including steps taken if dosages are not given or are missing.

While reviewing eMAR with S1, LPA David Doidge observed R2 had an extra box of medication opened before the previous box had been used. S1 informed LPA and LPM that the initial box had been misplaced and a new box was opened to prevent a mis-dose. S1 informed LPA and LPM that the facility had two boxes available, which was observed by LPA David Doidge. The initial box had fallen out of R2’s medication box while all medication were being transferred to a new medication cart the facility is now using. A few days later the initial box was found behind R2’s medication box and the med techs started using both boxes until S1 counted the contents of box two, made a note, then taped box two closed informing the other med techs to only use box one until remaining doses were used before using the second box. LPA David Doidge counted the contents of both boxes, reviewed eMAR and noted no missing doses. Therefore the 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 occur, therefore the allegation that staff did not administer medication to a resident in care is unsubstantiated.

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025

LIC9099 (FAS) - (06/04)

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