019201182-10-24-2023-15-AS-KHOS-CX4R2W-20231030123902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 10/24/2023
Date Signed: 10/24/2023 04:06:07 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
10/17/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20231017135613

FACILITY NAME:	LAKE PARK SENIOR LIVING		FACILITY NUMBER:	019201182
ADMINISTRATOR:	MEDINI, ROZA		FACILITY TYPE:	741
ADDRESS:	1850 ALICE STREET		TELEPHONE:	(510) 835-5511
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94612
CAPACITY:	275	CENSUS: 109	DATE:	10/24/2023
		UNANNOUNCED	TIME BEGAN:	03:08 PM
MET WITH:	Annmarie Dominici, Executive		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Facility staff does not ensure planned activities are posted in a readily accessible location for residents

INVESTIGATION FINDINGS:

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On 10/24/23 at 3:12PM, Licensing Program Analyst (LPA) conducted an unannounced complaint visit, met with executive director (ED), gathered information and delivered investigation finding of above allegation.

Allegation: Facility staff does not ensure planned activities are posted in a readily accessible location for residents
Investigation Finding: Unsubstantiated
During investigation, LPA toured the facility with ED and observed the glass encased poster displays for monthly planned activities were visibly accessible for public viewing (see 812 for more details). Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20231017135613

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: LAKE PARK SENIOR LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 10/24/2023

NARRATIVE

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ED stated that printed monthly planned activities are distributed directly to the residents a week prior to the start of the month's activities so residents can look over the schedules and sign up in advance for outings or preferred events. LPA also observed additional hard copies of the monthly planned activities were readily accessible at the front desk for residents' use. ED showed a binder of the monthly activities for residents that is also left at the front desk for residents' perusal if desired.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff does not ensure planned activities are posted in a readily accessible location for residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff does not ensure planned activities are posted in a readily accessible location for residents is unsubstantiated.

No deficiency cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
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

LIC9099 (FAS) - (06/04)

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