019201182-2-1-2024-15-AS-KHOS-D3AMA8-20240312092555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 02/01/2024
Date Signed: 02/01/2024 03:22:31 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
03/19/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230319183113

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:	01:50 PM
MET WITH:	Annemarie Domizio, Executive Director		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff person entered resident's unit by force without authorization

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 2/1/2024 at 1:50PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to delivered finding for the allegations above. LPA met with Excutive Director, Annwmarie Domizio and explained the purpose of the visit.

Allegation: Staff Person entered resident’s unit by force w/out authorization – Unsubstantiated

On 3/20/23 LPA KN interviewed R1, who stated he had requested to meet with S2 – and that without warning S2 arrived to the unit with S1. R1 stated he informed S1 that R1 did not need to meet with S1 and verbally would not allow S1 entrance to the apartment, with S1 stating that S1 was the Executive Director and had authorization to enter – and then did so.

Report Continued on LIC9099C...

Unsubstantiated

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)

Page: 1 of 2

Control Number 15-AS-20230319183113

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 3/20/23 LPA KN interviewed S1 and S2, who denied having forced their way into R1s apartment. S1 stated that R1 had made an appointment to meet in R1s unit. When S1, accompanied by S2 arrived, R1 welcomed both staff persons into the unit. LPA KN spoke to R2, who also resides in the unit, and found that R2 was not present during the event, and had not heard anything pertaining to the allegation. No other potential witnesses were identified.

No deficiency cited during visit.

Exit interview conducted 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)

Page: 2 of 2