019200529-1-8-2025-15-AS-HHUL-DDSQP3-20250211112004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 01/08/2025
Date Signed: 01/08/2025 04:48:11 PM

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
09/26/2024 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240926163458

FACILITY NAME:	LAKESIDE PARK		FACILITY NUMBER:	019200529
ADMINISTRATOR:	ESPINOZA, CHELSEA J		FACILITY TYPE:	740
ADDRESS:	468 PERKINS ST		TELEPHONE:	(510) 444-4684
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	76	CENSUS: 55	DATE:	01/08/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Grant Haywood, Executive Director		TIME COMPLETED:	05:08 PM

ALLEGATION(S):

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Neglect of resident in care

INVESTIGATION FINDINGS:

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On 1/8/2025 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegation above. LPA met with Executive Director, Grant Haywood and explained the purpose of the visit.

During the investigation, LPA interviewed 2 residents, 11 staff, and witness. LPA reviewed and obtained documents including staff schedule, staff roster with phone numbers, physician's report, care plan, progress notes, blood sugar logs, and emergency information.

Interview with staff and witness indicated that no residents are being neglect and residents are cared for at the facility. W3 stated that caregivers are doing a good job in caring for residents. Progress notes and communication documents revealed that the doctor was notified regarding R1's leg condition.
(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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-20240926163458

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: 01/08/2025

NARRATIVE

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Visiting documents and progress notes indicated that home health was visiting R1 for wound care on R1's legs. Home health would assist R1 in changing the dressings on R1's legs. R1 was admitted to hospice care on 9/20/2024 and hospice assisted in wound care for R1 after that date.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC9099 (FAS) - (06/04)

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