019201182-2-1-2024-15-AS-KHOS-D3AMPH-20240312094710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 02/01/2024
Date Signed: 02/01/2024 03:19:45 PM

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
03/14/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230314095133

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: 97	DATE:	02/01/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Annemarie Domizio, Executive Director		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility illegally evicted resident.
Facility hired an aide for resident without obtaining consent.

INVESTIGATION FINDINGS:

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On 2/1/2024 at 12PM, 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: Facility illegally evicted resident – Substantiated
On 3/20/23, LPA KN interviewed the RP (Reporting Party) who stated that RP was admitted to the facility under the previous licensee as a CCRC resident without memory care issues. On March 2, 2023, RP was informed that R1 had wanted to leave the building and had to be redirected back to her room; and that R1 would need to be moved to another facility with a memory care unit, or have a 1:1 aide around the clock. LPA reviewed the originating CCRC contract and observed that it stated that residents who develop memory care conditions would be retained by the facility. the current Licensee/facility is to adhere to existing contracts agreed upon with the previous Licensee.
Report Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (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)

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Control Number 15-AS-20230314095133

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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LPA obtained a copy of letter to R1, dated 3/12/23, whereby R1 was being evicted as the facility does not accept or retain memory care residents. On 3/20/23, LPA interviewed the Administrator who confirmed that the eviction letter was issued to R1 and that the family needed to hire/pay for an outside 1:1 aide. It was further found that per the terms of the sale of the business, the current Licensee/facility is to adhere to existing contracts agreed upon with the previous Licensee.

Deficiency is cited under California code, Health and Safety 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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (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)

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Control Number 15-AS-20230314095133

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(s)	1 2 3 4 5 6 7	1793.219(s). 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: (s) Failed to fulfill his or her obligations under continuing care contracts. This requirement was not met as evidence by:	1 2 3 4 5 6 7	POC: Provide proof of retriving the eviction letter from R1 to be submitted to CCLD by 2/16/24.
	8 9 10 11 12 13 14	Based on observation and record review, the licensee did not comply with the section cited above... LPA reviewed the originating CCRC contract and observed that it stated that residents who develop memory care conditions would be retained by the facility. LPA obtained a copy of letter to R1, dated 3/12/23, whereby R1 was being evicted as the facility does not accept or retain memory care residents. On 3/20/23, LPA interviewed the Administrator who confirmed that the eviction letter was issued to R1 and that the family needed to hire/pay for an outside 1:1 aide. It was further found that per the terms of the sale of the business, the current Licensee/facility is to adhere to existing contracts agreed upon with the previous Licensee.	8 9 10 11 12 13 14
Type B 02/16/2024 Section Cited HSC 1569.80	1 2 3 4 5 6 7	ARTICLE 7.5. Resident Participation in Decisionmaking [1569.80- 1569.80.] This requirement was not met as evidence by:	1 2 3 4 5 6 7	POC: Pull back the third party staff person and charges; and write addendum to the Plan of Operation describing how they will handle the need for necessary additional staff for a resident.
	8 9 10 11 12 13 14	Based on observation and record review, the licensee did not comply with the section cited above... On 3/20/2023 LPA KN interviewed the Administrator, who stated that the facility had informed the RP of a need for a 24 hour 1:1 aide. LPA found that the facility did not issue an advance 30-day written notice of a new need and the associated costs – as required.	8 9 10 11 12 13 14

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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (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)

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