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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 09/12/2022
Date Signed: 09/12/2022 03:39:24 PM


Document Has Been Signed on 09/12/2022 03:39 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:LAKE PARK SENIOR LIVINGFACILITY NUMBER:
019201182
ADMINISTRATOR:HAN, MINDYFACILITY TYPE:
741
ADDRESS:1850 ALICE STREETTELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 120DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Tammy Hauck, Executive Driector TIME COMPLETED:
03:45 PM
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On 9/12/2022 at 3:05PM, Licensing Program Analysts (LPAs) K. Nguyen arrived unannounced to conduct A case management. Upon arrival, LPAs met with Tammy Hauck Executive Director, and explained the purpose of the visit.

On 9/9/2022 at 10:30AM, Licensing Program Analysts (LPAs) K. Nguyen arrived unannounced to conduct Pre-licensing Inspection. Facility is currently licensed and pre-licensing is requested due to change of ownership.

LPA noticed that the pre-licensing was conducted on 9/9/22 was under the old facility number. LPA obtained the signature of Executive Director under the new facility number and deliver the report.

Exit interview conducted and a copy of this report provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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