019200529-12-4-2023-15-AS-HHUL-CZQUQM-20240122144720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 12/04/2023
Date Signed: 12/04/2023 01:37:14 PM

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
06/16/2023 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20230616104035

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: 51	DATE:	12/04/2023
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Sonia Taizan, Business Officer Manager		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff member sexually assaulted resident while in care

INVESTIGATION FINDINGS:

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On 12/4/2023 at 1:05pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, arrived unannounced to deliver complaint findings for the allegation above. LPA met with Sonia Taizan, Business Office Manager, and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews with staff, residents, witnesses, obtained and reviewed records. On the above allegation, facility staff member sexually assaulted resident while in care, R1 has resided at the facility since April 19, 2023. On June 11, 2023, R1 stated to W1 that he was sexually assaulted by a staff member while being assisted with toileting. R1 was able to give a description of the staff but did not know the staff’s name. The staff that were interviewed by the Department denied witnessing the allegation and some of them

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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-20230616104035

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: 12/04/2023

NARRATIVE

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Continued from LIC9099.

stated R1 has experienced hallucinating episodes while at the facility. The Department also interviewed residents who did not have any concerns and felt safe at the facility.

The Department reviewed Oakland Police Department’s report which indicated that on June 11, 2023, the police officers were dispatched to the facility and spoke with S1. The report also indicated the alleged incident occurred on June 9, 2023, which there was only one (1) male caregiver that worked that night. S1 also stated in the report that there are only two (2) male caregivers that worked at the facility.

During the interview with S2 it was stated that S3 was assigned to R1 that night and on the NOC shift staff conducted checks on the residents every two hours. The staff try not to wake up the residents when conducting their routine checks, but that R1 regularly wakes up when he’s being assisted. S2 stated R1 had described the male staff and S3 was the only male staff working. Facility staff contacted the agency where S3 was employed and requested S3 to be removed from the rotation due to the allegation.

The Department interviewed W1, the Director from the agency where the male staff was hired. W1 was aware of the incident that occurred at Lakeside and conducted an internal investigation at the agency. W1 stated that the male staff did give a statement stating he did assist R1 with toileting and had to assist by putting his hand on R1’s private part to place in urinal cup.

Continued on LIC9099C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230616104035

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: 12/04/2023

NARRATIVE

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Continued from LIC9099C.

Based upon the information obtained and the interviews during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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

Exit interview conducted. A copy of this report is provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

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