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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200529
Report Date: 10/02/2024
Date Signed: 10/02/2024 01:19:00 PM

Document Has Been Signed on 10/02/2024 01:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAKESIDE PARKFACILITY NUMBER:
019200529
ADMINISTRATOR/
DIRECTOR:		ESPINOZA, CHELSEA JFACILITY TYPE:
740
ADDRESS:468 PERKINS STTELEPHONE:
(510) 444-4684
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 76CENSUS: 54DATE:
10/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Grant Haywood, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 10/2/2024 at 12:30PM, Licensing Program Analysts (LPAs) G. Luk and D. Doidge arrived unannounced to conduct a case management visit. LPAs met with Executive Director, Grant Haywood and explained the purpose for the visit.

While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20240926163458), the following deficiency was observed.

After reviewing Guardian system, LPAs observed staff (S1) did not have criminal record exemption transfer to this facility. S1 left the facility during visit and will return once exemption transfer is approved.

Civil penalty of $100 is being assessed.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2024 01:19 PM - It Cannot Be Edited


Created By: Grace Luk On 10/02/2024 at 12:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKESIDE PARK
FACILITY NUMBER: 019200529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2024
Section Cited
CCR
87411(g)(3)

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Personnel Requirements - General. Request and be approved for a transfer of a criminal record exemption... This requirement is not met as evidence by:
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Facility has agreed to obtain criminal record exemption transfer for S1 and submit proof of communication to Guardian to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not having criminal record exemption transfer for staff which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $100 is being assessed.

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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
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