019200529-5-22-2024-15-AS-KHOS-D97K5S-20240917073624

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 05/22/2024
Date Signed: 05/22/2024 02:38:17 PM

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
05/20/2024 and conducted by Evaluator Alona Gomez

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240520122256

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:	05/22/2024
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Executive Director, Grant Haywood		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff hid resident's medication in their food

INVESTIGATION FINDINGS:

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On 5/22/2024 at 9:55 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Grant Haywood, Executive Director (ED) and explained the purpose of the visit.

During the visit LPA obtained copies of resident's (R1, R2, and R3) care plans, phycisians reports, care notes, staff roster, staff schedules for February-Current, residents roster, and a current copy of the MAR. LPA interviewed S1, S5, and S6. S2, S3, and S4 were off and unavailable to be interviewed. R1, R2, and R3 have dementia and declined interviews. LPA observed "ok to crush meds" orders from pysician for R3.

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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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