<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 09/04/2024
Date Signed: 09/04/2024 12:22:08 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
08/28/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240828085620
FACILITY NAME:LAKESIDE PARKFACILITY NUMBER:
019200529
ADMINISTRATOR:ESPINOZA, CHELSEA JFACILITY TYPE:
740
ADDRESS:468 PERKINS STTELEPHONE:
(510) 444-4684
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:76CENSUS: 57DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:GRANT HAYWOOD, EXECUTIVE DIRECTORTIME COMPLETED:
12:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not keep the facility free from mold
Staff do not properly maintain the facility's drainage system
Staff do not provide adequate laundry service for the residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day 9/04/2024, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct 10-day investigation on the above allegation and met with Executive Director, Grant Haywood, LPA explained the purpose of the visit.

During the visit, LPA toured the facility including but not limited to kitchen area, and three (3) laundry room areas floors one (1) and two (2) and interviewed staff 1 (S1), staff 2 (S2), staff 3 (S3) and staff 4(S4). LPA obtained the following records staff roster with contact information, shower/laundry/lienen schedule and Direct Supply Tels plumbing service invoices.

Continue on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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-20240828085620
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: 09/04/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
continue from LIC 9099

Allegation: Staff do not keep the facility free from mold
Investigation Finding: unsubstantiated.

LPA toured the facility including the kitchen area walk in refrigerator and freezer and there were no signs of mold. Interviews with S1, S2 and S3 there has not been a mold issue that staff is aware of.

Allegation: Staff do not properly maintain the facility's drainage system


Investigation Finding: unsubstantiated.

Interview with S1 and S2 revealed that there has not been a drainage issue at the facility. S2 stated there has been normal toilet backups due to residents over use of toilet paper and flushing paper towel, diapers and other non-flush able items.

Allegation: Staff do not provide adequate laundry service for the residents


Investigation Finding: unsubstantiated.

Interview with S2, S3 and S4 revealed that residents laundry is serviced daily. S4 stated that laundry for each resident is conducted the same day as their shower schedule, however, if a residents laundry is full staff will wash their laundry. S2 and S3 stated that if there is an issue with the washer and dryer on the 1st or 2nd floor the large laundry room will wash or dry the residents laundry. S3 stated that the large laundry room is for washing residents linen, which is washed daily and also stated that if there is an issue with one of the washers or dryers on the 1st and 2nd floor the residents laundry will be serviced in the large laundry room.




Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2