019201182-2-9-2024-15-AS-KHOS-D2DNJ7-20240212092953

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:23:20 PM

Unsubstantiated

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
02/07/2024 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240207121356

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: 100	DATE:	02/09/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director Annemarie Domizio		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff not following resident's care plan.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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On 2/9/2024 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility unannounced to conduct an initial 10-day complaint investigation visit concerning the allegations above. Upon entry, the LPA informed Business Office Manager (BOM) of the purpose of the visit. The BOM informed the Executive Director (ED) Annemarie Domizio by phone.

Allegation: Staff not following resident's care plan. – Unsubstantiated
On 2/9/2024, the LPA interviewed Staff S1. S1 stated that there had been no disruption in R3’s showers that are sometimes bed baths due to R3’s frailty. The entries in the shower log showed that they received showers or bed baths on a weekly basis, which was 4 times during the month of January 2024.

Report Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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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Control Number 15-AS-20240207121356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKE PARK SENIOR LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 02/09/2024

NARRATIVE

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...Report Continued from LIC9099

Allegation: Facility is in disrepair. – Unsubstantiated
On 2/9/2024, the LPA interviewed Staff S1 about the amount of time that the shower was not available for residents during the renovation of the handicap accessible shower on the third floor. S1 stated that the time for the renovation was 4 days and that there had been no disruption in care for residents, as was verified by the entries in the shower log.

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

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