019200529-1-24-2025-15-AS-BFOG-DDL4AH-20250204175559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 01/24/2025
Date Signed: 01/24/2025 10:41:08 AM

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
12/18/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20231218154753

FACILITY NAME:	LAKESIDE PARK		FACILITY NUMBER:	019200529
ADMINISTRATOR:	JULIE PETERSON		FACILITY TYPE:	740
ADDRESS:	468 PERKINS ST		TELEPHONE:	(510) 444-4684
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	76	CENSUS: 56	DATE:	01/24/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jocelyn Fabros, Resident Care Director		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Facility does not have a certified Administrator.
Facility staff do not ensure resident rooms are kept clean.
Facility staff are not ensuring a resident's grooming needs are met.
Facility staff did not properly maintain a resident's room.
Facility staff do not ensure that residents are fed.

INVESTIGATION FINDINGS:

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On 1/24/25 at 9:45 a.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Jocelyn Fabros; Resident Care Director explained the purpose of the visit. Executive Director was not available during the time of visit but gave verbal permission to sign the report.

Allegation: Facility does not have a certified Administrator: Unsubstantiated

LPA conducted interview S1 to confirmed that the facility has a certified Administrator during the leave of the pervious ED. S1 stated that there was an interim Executive Director (ED) that took place of the previous ED while she was on leave. LPA reviewed recorded shows that the facility has a certified Administrator at the facility.

Report Continued on LIC 9099c...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

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-20231218154753

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: 01/24/2025

NARRATIVE

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Allegations: Facility staff do not ensure resident rooms are kept clean, Facility staff did not properly maintain a resident's room, and Staff do not properly maintain the resident’s room: Unsubstantiated

LPA tour the facility and randomly sample 10 residents room including and not limited to Piedmont Manor and Merritt House. LPA observed that 10 out of 10 residents’ room properly maintain. LPA observed residents’ beds are made, and no smell of odor. LPA reviewed housekeeping and laundry log for the month of April till present and it indicated that housekeeping is keeping track of the room/ floor that they are responsible. There are rooms that housekeeper must clean daily including and not limited to room 102, 104, 114, 117, 121, 125B, 209A, and 222.

Allegation: Facility staff are not ensuring a resident's grooming needs are met: Unsubstantiated

LPA conducted interview with R1, R2, and R3 regarding their grooming needs are being met by the facility staff. 3 out of 3 stated that the facility staff are great and does meet their grooming needs. R2 stated when R2 needs any assistance with bathing staff would assist R2. R1 stated “something I don’t need any assistance with grooming, so I refused their assistance”. R3 stated “my needs are being meet, and I have no complaint about any assistance not meeting my expectations”.

Allegation: Facility staff do not ensure that residents are fed: Unsubstantiated

LPA interviewed R1, R2, and R3 regrading the above allegation of facility staff do not ensure that residents are fed. 3 out of 3 stated “I get fed three time a day, but something I don’t want to eat so I refused it”. R3 stated “when I refused my meal, staff comes around after and check in with me to encourage me to eat”. LPA reviewed residents care note shows that staff are following their round checking in with residents if they refused their meal”.

Based on interviews and record reviews conducted, the above allegations 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 allegations are unsubstantiated.

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC9099 (FAS) - (06/04)

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