019200529-5-22-2024-15-AS-KHOS-DA9SRA-20241021140602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 05/22/2024
Date Signed: 05/22/2024 02:36:16 PM

Unfounded

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-20240520161618

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:	01:00 PM
MET WITH:	Executive Director, Grant Haywood		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility doesn’t have an emergency disaster plan

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/22/2024 at 1:00 PM, 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 emergency disaster plan, and log of disaster drills. LPA interviewed ED, and S1. S2, and S3 were off and unavailable to be interviewed. LPA observed emergecy evacuation chair available in 1 of the 2 stairwells.

This agency has investigated the complaint alleging that the Facility doesn’t have an emergency disaster plan. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

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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