019200529-3-10-2023-15-AS-KHOS-CQDMRK-20230329095029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 03/10/2023
Date Signed: 03/10/2023 11:50:42 AM

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
03/02/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230302140641

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: 45	DATE:	03/10/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Sonia Taizan, Business Office HR Director Julie Peterson, Executive Director		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Resident was on the floor unattended
Resident's room was cold
Resident's room unkept

INVESTIGATION FINDINGS:

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On 03/10/23 at 9:50AM, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced, conducted interviews, gathered & analyzed the information ibbtained relevant to the allegations, and delivered the investigation findings. LPA met with Business Office HR Director (BD)and spoke to Executive Director (ED) on the phone who authorized BD to act on her behalf and sign the reports. LPA explained the purpose of the visit with BD and ED.

BD stated that the facility is currently under COVID-19 quarantine with 11 residents on the 2nd floor positive with COVID as well as 3 staff. LPA observed 4 staff on duty on the 2nd floor wearing PPEs and red zone area was identified. Staff is currently working with local Public Health in following COVID protocols and testing schedules have been established until all residents and staff are cleared. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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-20230302140641

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: 03/10/2023

NARRATIVE

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Allegation: Resident was on the floor unattended
LPA reviewed a risk management incident report dated 02/25/23 which showed resident (R1) had an unwitnessed fall on the side of the bed. S2 stated R1 had a bowel movement during the incident and did not complain of any pain at the time she was observed. S2 stated that staff along with R1's caregiver assisted R1 and was cleaned, diaper and beddings changed. S2 stated that residents are checked and monitored every 2 hours. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident was on the floor unattended did occur, therefore the allegation is unsubstantiated.

Allegation: Resident's room was cold
During visit, LPA observed resident's (R1) room temperature at 70 deg F per thermostat reading inside her bedroom. LPA also observed hallway temperature at 75 deg F per thermostat reading. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident's room was cold did occur, therefore the allegation is unsubstantiated.

Allegation: Resident's room unkept
LPA toured the 2nd floor with BD during visit. LPA observed residents' rooms (Rm 215 and 216) odor free with windows closed. LPA observed resident (R1) sitting comfortably in a chair next to the closed window. LPA observed R1 to be clean and well groomed. LPA did not see any soiled diaper or dirty clothing inside the bedroom. LPA observed R1' room to be clean and odor free with a few clean clothes sitting on a chair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident's room was unkept did occur, therefore the allegation is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

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