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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 01/23/2025
Date Signed: 01/23/2025 11:08:01 AM

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
05/08/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240508084053
FACILITY NAME:LAKESIDE PARKFACILITY NUMBER:
019200529
ADMINISTRATOR:ESPINOZA, CHELSEA JFACILITY TYPE:
740
ADDRESS:468 PERKINS STTELEPHONE:
(510) 444-4684
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:76CENSUS: 61DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Grant Haywood, Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not ensure the residents are properly fed
Staff do not ensure the residents consume an appropriate amount of liquid
Staff do not prevent the residents from sustaining injuries while in care
Staff allow the residents to be soiled for an extended period of time
Staff do not properly maintain the residents room
Staff do not provide the residents assistance to the restroom
INVESTIGATION FINDINGS:
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On 1/23/25 at 10:00 a.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Executive Director, Grant Haywood explained the purpose of the visit.

Allegation: Staff do not ensure the residents are properly fed: Unsubstantiated

LPA interviewed R1 regrading R1 not receiving meal or not being fed properly. R1 stated “I get fed three time a day, but something I don’t want to eat so I refused it”. RP stated sometime R1 said R1 doesn’t want to eat during that time. S1 stated that care staffs make their round every other hours to make sure to remind residents to eat if they refused the first time.

Report Continue on LIC 9099c...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20240508084053
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: 01/23/2025
NARRATIVE
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Allegation: Staff do not ensure the residents consume an appropriate amount of liquid: Unsubstantiated

LPA reviewed care notes that staff are encouraging R1 to drink more liquid. LPA interview S1 stated that R1 doesn’t like to drink the amount of liquid that are given to R1. S1 indicated that even when staff encouraged R1, R1 tend to ignore and said “yea…yea…I know”. LPA interview R1, R1 stated that R1 doesn’t like to drink a lot of liquid. Staff goes around and offered beverages, but R1 doesn’t want to take the offered. R1 stated R1 doesn’t like to drink a lot of liquid (repeated twice).

Allegation: Staff do not prevent the residents from sustaining injuries while in care: Unsubstantiated

LPA interviewed S1, R1, R2, and R3. S1 stated that staff do there ensured checked with residents every four hours. Staff walked around to monitor residents. Residents that stay in their room have their door open or half open, so staff do their walk through. R1 stated that staff checked on me often, because R1 stated that R1 likes to stay in R1 room. R1 stated that “I am an old man so it’s normal that I fall. I don’t like to ask for help because I like to be independent”. S1 noticed that R1 likes to be in R1 socks and doesn’t like to put on slipper. R1 likes to do things independently, and when R1 wear socks the floor can be slippery R1 can fall, so staff pays more attention to R1 to prevent R1 from falling. S1 stated same goes with other residents if they refused then staff can’t force them, but to keep on encouraging. Staff encouraged R1 to wear slipper, but R1 refused, S1 stated most of the residents doesn’t like to be help they like to do thing themselves.


Report Continue on LIC 9099c...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20240508084053
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: 01/23/2025
NARRATIVE
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Allegation: Staff allow the residents to be soiled for an extended period of time: Unsubstantiated

LPA interviewed S1, R1, R2, and R3 regarding the duration of times that staff allow the residents to be soiled for an extended period of time. S1 stated that residents don’t want to be change at time, and staff have to just encouraged residents. R1 stated R1 doesn’t like to ask for assistance, and staff comes and provide the assistance, but R1 refused at time. R2, and R3 stated they don’t wait for a long time for staff to come and change them whenever they have an accident.

Allegation: Staff do not properly maintain the resident’s room: Unsubstantiated

LPA tour the facility and randomly sample 10 residents room including and not limited to Piedmont Manor and Merritt House. LPA observed that 10 out of 10 residents’ room properly maintain. LPA observed residents’ beds are made, and no smell of odor. LPA reviewed housekeeping and laundry log for the month of April till present and it indicated that housekeeping are keeping track of the room/ floor that they are responsible. There are rooms that housekeeper must clean daily including and not limited to room 101, 102, 103, 104, 105, 118, 122, and 124.


Report Continue on LIC 9099c...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20240508084053
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: 01/23/2025
NARRATIVE
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Allegation: Staff do not provide the residents assistance to the restroom. Unsubstantiated

LPA interviewed R1, R2, and R3 regrading if staff assist with restroom. 3 out of 3 stated that staff do assist them with the restroom when they needed. R1 stated most time R1 doesn’t like to ask for assistance and doesn’t want assistance from staff because R1 stated that R1 can use the restroom without any assistance. S1 stated that when residents refused, they cannot force them. Care staff are to do their round and go a check back with those residents that refused and offered their assistance to the residents. RP stated “at time residents refused staff assistance and want to use the restroom themselves””.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.



Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4