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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 02/01/2024
Date Signed: 03/12/2024 08:48:00 AM

Substantiated


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
03/10/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230310131125
FACILITY NAME:LAKE PARK SENIOR LIVINGFACILITY NUMBER:
019201182
ADMINISTRATOR:MEDINI, ROZAFACILITY TYPE:
741
ADDRESS:1850 ALICE STREETTELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 97DATE:
02/01/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Annemarie Domizio, Executive DirectorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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9
Insufficient Food Service
Facility not providing security personnel per admission agreements
Facility staff not according residents dignity
Facility interfering with residents exercising rights
INVESTIGATION FINDINGS:
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On 2/1/2024 at 9:30AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to delivered finding for the allegations above. LPA met with Executive Director, Annemarie Domizio and explained the purpose of the visit.

Allegation: Insufficient Food Service – Substantiated
On 4/6/23 and 4/7/23, CCRC AGPA Jennifer Walden interviewed S1, S2, S3, and S4; and obtained an email notification from the facility to residents regarding food service changes and the elimination of the salad bar and the buffet – effective 1/14/23, dining committee notes, the Resident Service Agreements generated under the previous Licensee, and Town Hall Meeting notes from 12/29/22 which stated that the Administrator informed the residents that the salad bar and buffet would removed completely.

AGPA JW found that the facility had changed and eliminated components of the food service without providing at least 30 days written notice, and that the Licensee Provider had not held a meeting 60 days prior to adjustments in “policies, programs, or services that would materially change the operation or environment of the community as required by the Health & Safety Code and CCRC requirements.”

Report Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
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 7
Control Number 15-AS-20230310131125
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: 02/01/2024
NARRATIVE
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Allegation: Facility not providing security personnel per admission agreements – Substantiated

On 3/20/2023 LPA KN obtained reviewed the CCRC contracts of residents admitted under the previous licensee, which indicated that the facility would provide 24 hour security guard service. LPA found that per the terms of the facility sale, the current licensee was to honor the existing CCRC contracts and Admission Agreements. LPA observed that the agreement generated under the previous Licensee provided that the Licensee “maintains a 24-hour emergency call system, a security entrance system, and security personnel. LPA interviewed R1 through R10 who stated that after the sale, the current Licensee terminated the guard service and assigned monitoring of the front door to staff employed directly by the facility who had other primary responsibilities (front desk staff). On 4/6/23 and 4/7/23, AGPA JW interviewed S1 through S4 and obtained an email communication between the facility and residents – which stated that the services of an outside Security Service were only in place until the Saturday/Sunday positions were filled and that front desk staff and additional personnel would provide security during working hours.

R1 through R4 stated that there are times when no staff are near the entrance. LPA interviewed S1 who confirmed that the security service had been terminated.

Report Continued on LIC 9099C...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
03/10/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230310131125

FACILITY NAME:LAKE PARK SENIOR LIVINGFACILITY NUMBER:
019201182
ADMINISTRATOR:MEDINI, ROZAFACILITY TYPE:
741
ADDRESS:1850 ALICE STREETTELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 97DATE:
02/01/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Annemarie Domizio, Executive DirectorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient Activities
INVESTIGATION FINDINGS:
1
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3
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5
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9
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13
On 2/1/2024 Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to delivered finding for the allegations above. LPA met with Excutive Director, Annemarie Domizio and explained the purpose of the visit.

Allegation: Insufficient Activities – Unsubstantiated
On 4/6/23 and 4/7/23, AGPA Jennifer Walden interviewed S1, S2, S3, and S4 and obtained the February, March & April Activities calendars, emails between residents & the facility, and the Residence and Service Agreements generated under the previous Licensee. On 3/20/2023 LPA KN toured the facility including but not limited to the exercises and activities room. LPA observed that facility has an activities calendar posted by the elevator. Also on 3/20/23, LPA KN interviewed R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 with all stating that there are activities provided throughout the day and that it is their choice whether or not to participate. Based on the Activities Calendars, correspondence with residents and interviews with S1 through S4, the activities being provided meet both CCR and CCRC requirements.
No deficiency cited during visit.
Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20230310131125
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: 02/01/2024
NARRATIVE
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Allegation: Facility staff not accorded residents with dignity – Substantiated

On 3/20/2023 LPA KN interviewed RP and R1 through R10 who stated that S1 does not treat them with dignity, with RP stating that S1 had yelled at them during council meetings. R1 further stated that the facility informed residents that it was not a Continuing Care Retirement Community, had threatened residents with higher charges and/or eviction if new agreements were not signed, and that the facility would not address their concerns regarding the facility’s CCRC status. R5 reported that S1 has lied to the residents when discussing the terms of the existing CCRC agreements that were to be adhered to, with S1 stating that there were no residents at the facility under CCRC agreements. On 3/20/23, LPA KN interviewed the Administrator, who stated that the facility is not a CCRC. Based upon resident and Administrator interviews the facility did not adhere to the H&SC code indicating that the residents shall have a right “to live in an environment that enhances personal dignity.”

Report Continued on LIC 9099C...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20230310131125
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: 02/01/2024
NARRATIVE
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Allegation: Facility interfering with residents exercising rights – Substantiated

On 3/20/23 LPA KN interviewed the RP who stated that R13 was informed by the facility that R13 would need to be moved from an Independent to an Assisted Living Unit, and was being required to sign a new Residence & Care Agreement. LPA observed that the original agreement generated under the previous licensee (and per the terms of the sale the current Licensee is required to adhere to original agreements) states that a new agreement was not required when transferring to Assisted Living. On the same date, LPA interviewed the Administrator who confirmed that R13 needed to be transferred and that a new agreement was required. LPA further found that R13 was moved from the Independent unit to a temporary Assisted Living unit due to refusal to sign a new agreement. This resulted in material misrepresentation made to a resident with an existing CCRC agreement.

Deficiency is cited under the California Health and Safety Code listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with, Business Office Manager Aryanna Henry. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20230310131125
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2024
Section Cited
HSC
1771.8(s)(2)(a)
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Complainant alleges that the Provider’s food service is insufficient and in violation of Health & Safety Code (H&SC) §1771.8(s)(a) which states that Provider “Failed to fulfill his or her obligations under continuing care contracts.”

This requirement was not met as evidence by:
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POC: addendum to Plan of Operation describing how they will meet the H&SC code requiring formal written notice and/or meetings 60 days in advance of changes.
POC must be submitted to CCLD by: 2/16/24
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Based on observation and record review, the licensee did not comply with the section cited above...

AGPA JW found that the facility had changed and eliminated components of the food service without providing at least 30 days written notice, and that the Licensee Provider had not held a meeting 60 days prior to adjustments in “policies, programs, or services that would materially change the operation or environment of the community as required by the Health & Safety Code and CCRC requirements.”

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Type B
02/16/2024
Section Cited
HSC
1793.2(s)
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Complainant alleges that the Provider stopped providing security personnel as provided in the Residence and Services Agreement which was a violation of Health & Safety Code (H&SC) §1793.21(s) which states that Provider “Failed to fulfill his or her obligations under continuing care contracts.”.

This requirement was not met as evidence by:
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POC: security agency re-established covering (which hours); and self certify re-reviewing the original CCRC contract and understanding that 24 hour security guard service is to be covered.
POC must be submitted to CCLD by: 2/16/24
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Based on observation and record review, the licensee did not comply with the section cited above...
The interviews were held as listed above. The following documents were reviewed:

• February 28, 2023 email from ED to residents
• Front Desk calendar for March 2023
• Approved Residence and Services Agreements from Methodist Homes and Lake Park Senior Living
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20230310131125
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2024
Section Cited
HSC
1793.21(c)(2)
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Health & Safety Code (H&SC) §1793.21(c)(2) which states residents shall have a right “To live in an
environment that enhances personal dignity, maintains independence, and encourages self-determination.

This requirement was not met as evidence by:
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POC: new/current Admin self certify reading the Personal Rights Regulations (insert RCFC personal rights regulation, and
H&SC 1771.7(c)(2), understands them and will adhere to them.
POC must be submitted to CCLD by: 2/16/24
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The interviews were held as listed above. The following documents were reviewed:
• Approved Residence and Services Agreements from Methodist Homes and Lake Park Senior Living

Based on interviews with the residents during the December 29, 2022 Town Hall meeting and on separate occasions the ED at the time informed residents that the community was not a continuing Care Retirement community.
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Type B
02/16/2024
Section Cited
HSC
1793.21(t)
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Health & Safety Code (H&SC) 1793.21(t)
The department, in its discretion, may condition, suspend, or revoke any permit to accept deposits, provisional certificate of authority, or certificate of authority issued under this chapter if it finds that the applicant or provider has done any of the following:
(t) Made material misrepresentations to depositors, prospective residents, or residents of a continuing care retirement community.

This requirement was not met as evidence by:
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POC: new/current Admin self certify reviewing the original CCRC contract and H&SC 1793.21(t), and understands and will adhere to them.
POC must be submitted to CCLD by: 2/16/24
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Based on interviewed:
A resident who lived in a residential living units (RLUs) needed to move to an Assisted Living Units (ALU) and was being to asked to sign new Residence & Care Agreements even though the original agreement with Methodist was in effect and that agreement did not require residents to sign a new admission agreements when moving to an ALU. This resident was housed in a temporary ALU and he and his family were told by the ED that he would not be moved to a permanent unit until a new agreement was signed.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7