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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200529
Report Date: 10/24/2023
Date Signed: 10/24/2023 12:45:04 PM


Document Has Been Signed on 10/24/2023 12:45 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: 43DATE:
10/24/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ieshiaa Ragland, Program DirectorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management visit in connection with a Priority 1 complaint #15-AS-20231020144049 and met with Program Director Ieshiaa Ragland. LPA explained to Ieshiaa the purpose of the visit.

The facility is a three storey building. All the offices are located on the street level area. Residents are located on the next two levels. The facility serves clients with Dementia. There were 23 residents on the 1st level and 20 residents on the 2nd level. Residents were observed engaged in different activities. Residents appeared to be neat and well groomed. Facility was clean and odor free.

LPA with Program Director and Maintenance Director checked hot water in Merritt, Berkeley and Piedmont areas and observed at temperature was at 127.4 degrees Fahrenheit.

Type A deficiency is cited per Title 22 California Code of Regulations (see Lic 809D).

Exit interview was conducted with Ieshiaa and Appeal Rights was provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/24/2023 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2023
Section Cited
CCR
87303(e)(2)

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87303(e)(2) Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water.
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By POC date, 1) facility will adjust hot water temperature within the range of 105-120 and 2) facility will submit a plan on how to ensure hot water temperature is within range.
Facility will submit self certification stating hot water has been adjusted.
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 Hot water temperature controls shall be maintained .... temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by: Hot water in 3 diff faucets measured at 127.4F which poses an immediate risk to health and safety of residents in care.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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