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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 05:57:27 PM


Document Has Been Signed on 03/28/2024 05:57 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 - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Annemarie Domizio, Executive DirectorTIME COMPLETED:
04:00 PM
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On 03/28/2024 at 2:30 PM, Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Health and Safety check to address utilities are running, if there is any garbage build up anywhere on site, whether the facility is clean and how the residents are looking. LPA explained the purpose of the visit with Executive Director, Annemarie Domizio.

During health and safety check, LPA observed a total of 3 staff members and 3 residents at facility. LPA toured facility with staff (S1), including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health and safety concerns on today's date.

Documents Obtained:
  1. Copy February 2024 Activity Calendar
  2. Copy Week 4 of Breakfast, Lunch and Dinner Menu

No deficiencies cited during the Health and Safety check. Exit interview conducted and a copy of this report 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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