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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200529
Report Date: 06/19/2023
Date Signed: 06/19/2023 01:04:17 PM


Document Has Been Signed on 06/19/2023 01:04 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:JULIE PETERSONFACILITY TYPE:
740
ADDRESS:468 PERKINS STTELEPHONE:
(510) 444-4684
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:76CENSUS: 47DATE:
06/19/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lee Kaufmann, Managing DirectorTIME COMPLETED:
01:15 PM
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On 6/19/2023 at 12:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint. LPA met with Lee Kaufmann, Managing Director and explained the reason for the visit.

Upon arrival, LPA was greeted the receptionist. During the health and safety check LPA toured the facility with the Managing Director including but not limited to common areas, bedrooms and kitchen. LPA observed on the 2nd floor residents were having lunch and a couple of the residents were walking around. On the 1st floor LPA observed residents in common area. Facility is noted to be clean and in good repair and residents in care appear to be safe. There are no imminent health/safety concerns on today's date.

No deficiencies were cited today.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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