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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 03/28/2024
Date Signed: 03/28/2024 05:54:42 PM


Document Has Been Signed on 03/28/2024 05:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 103DATE:
03/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Annemarie Domizio, Executive DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 03/28/2024 at 12:30 PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, Annemarie Domizio.

Pertaining to complaint 15-AS-2024 0220153014, LPA L. Alexander had on 2/21/24, 2/28/24, 2/29/24, 3/1/24, 3/11/24, 3/12/24, and 3/13/24 requested documents and information related to the payment history for all utility accounts, service vendors, the latest invoices/statements paid and the status of outstanding balances. To date, the facility has not provided an accounting of the services related to gas & electricity; and garbage/recycling/organic/bulky waste collection.

Documents obtained:

Resident Registry List dated 03/22/24
Copy of Synergy Bill Details from dates 09/28/23 thru 03/28/24

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/28/2024 05:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
87755(b)

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87755 Inspection Authority of the Licensing Agency

(b) The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility.
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Administrator agrees to submit a full accounting of all utility bills and vendor accounts that had outstanding balances specifically PG&E and WM accounts to CCLD by POC due date.
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Based on record review, the licensee did not comply with the section cited above by providing requested account documents for utilities, vendors accounts and status of outstanding payments which poses an immediate health and safety risk to persons in care.
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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: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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