019200529-11-29-2022-15-AS-KHOS-CLUNH8-20221206092819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:50:01 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
11/09/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20221109151341

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: 44	DATE:	11/29/2022
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Julie Peterson, Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility staff do not following COVID guidelines

INVESTIGATION FINDINGS:

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On 11/29/22 at 2:05pm, Licensing Program Analyst (LPA) C. Lin arrived unannounced a subsequent complaint visit to investigate the above allegation. LPA met with Administrator and informed the purpose of visit.

The Department has investigated this allegation and per records review and interviews and found that facility didn’t follow Covid-19 guidelines from Alameda Public Health (APH). The Healthcare-Associated Infections (HAI) report from APH indicated that during the Covid outbreak from 10/28/2022 to 11/10/2022, facility had an incident that staff allowed a Covid positive resident to sit in the common area where came across with negative residents and staff; Covid positive and negative residents shared shower room;

Continue LIC9909-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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-20221109151341

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKESIDE PARK	FACILITY NUMBER: 019200529
	VISIT DATE: 11/29/2022

NARRATIVE

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facility has not designated staff to care only for Covid positive residents; and staff caring for resident with Covid did not avoid co-mingling with other staff members. APH staff visited and corrected facility on 11/10/2022. Facility Covid positive cases were significantly dropped after corrections were made.
Based on information obtained, the preponderance of evidence is met, therefore the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan of correction were discussed with Administrator. Exit interview conducted, Appeal Rights, LIC9099D, and a copy this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20221109151341

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKESIDE PARK	FACILITY NUMBER: 019200529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/06/2022 Section Cited CCR 87470(b)	1 2 3 4 5 6 7	87470 Infection Control Requirements (b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a communicable disease, the following shall apply: This requirement is not met as evidenced by…	1 2 3 4 5 6 7	Deficiency Cleared. Administrator have retrained all staff regarding infection control protocol and provided a copy of training record to CCLD during visit.
	8 9 10 11 12 13 14	Based on observation, record reviews, and interviews, the licensee did not comply with the section cited above, where facility didn’t follow infection control protocol instructed by Alameda Public Health which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

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