019200529-1-21-2026-15-AS-BFOG-DRL3X2-20260223173736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 01/21/2026
Date Signed: 01/21/2026 11:17:24 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
07/31/2024 and conducted by Evaluator David Doidge

COMPLAINT CONTROL NUMBER: 15-AS-20240731152640

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: 52	DATE:	01/21/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Resident Care Director Jocelyn Fabros		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff did not properly address resident’s multiple falls at facility.

Staff did not prevent outbreak of scabies

INVESTIGATION FINDINGS:

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On 01/21/2026 at10:30 AM, Licensing Program Analyst (LPA), David Doidge arrived unannounced to deliver complaint findings for the allegations above. LPA met with Resident Care Director Jocelyn Fabros and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with Witness 1 (W1), Staff 1 (S1), LPA reviewed and received a copy of staff and facility roster, physicians reports for R1, progress notes, physician communication form, admission agreements, Appraisal needs and service plans, and resident appraisals.

Allegation: Staff did not properly address resident’s multiple falls at facility.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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 3

Control Number 15-AS-20240731152640

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKESIDE PARK	FACILITY NUMBER: 019200529
	VISIT DATE: 01/21/2026

NARRATIVE

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Continued from LIC9099

Investigation Finding: unsubstantiated.

During the investigation LPA interviewed W1 and S1. W1 reported concerns regarding R1’s multiple falls and stated the facility did not notify W1 on one occasion When R1 had a serious fall and was transferred to the hospital or returned to the facility. W 1 also stated that staff were not attentive to R1 and that R1 was often observed ambulating unsupervised throughout the facility, despite the facility being aware that our one was a fall risk. Find the interview with S1 stated that R1 was permitted to ambulate freely within the designated areas of the facility and that there were no physician orders indicating that R1 was non ambulatory. S1 further stated that the facility notified R ones responsible party each time R1 experienced a fall and that the physician was informed after each incident. The LPA conducted record review our facility records including progress notes physician communication forms which confirm that the responsible party and physician were notified following each fall based on interviews and record review the allegation is unsubstantiated.

Allegation: Staff did not prevent outbreak of scabies.

Investigation Finding: unsubstantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240731152640

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKESIDE PARK	FACILITY NUMBER: 019200529
	VISIT DATE: 01/21/2026

NARRATIVE

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Continued from LIC90999

During the investigation LPA interviewed W1 and S1. W1 stated that during a visit with R1, a resident approached and began petting W 1's dog. W one reported that a staff member (name unknown) informed W one that the resident had scabies and that the resident had wandered from a quarantine area. S1 stated that the facility experienced A scabies outbreak and that all symptomatic residents were quarantined in their rooms on the 2nd floor. Staff assigned to the second floor worked exclusively with quarantine residents. Residents who were not quarantined were allowed to ambulate throughout the facility except for the second floor. S1 further stated that a physician evaluated the situation and prescribed preventative medication to residents. The facility was unable to determine which resident initially introduced scabies into the facility. S1 confirmed that the facility followed its outbreak control policy. Based on interviews and record review this allegation is unsubstantiated.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC9099 (FAS) - (06/04)

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