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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 05:59:26 PM


Document Has Been Signed on 03/28/2024 05:59 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:
04:00 PM
MET WITH:Annemarie Domizio, Executive DirectorTIME COMPLETED:
06:15 PM
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On 3/28/2024 at 4:00 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit pertaining to information received by the Department indicating that the facility intends to rent units to independent 55+ individuals and persons with Section 8 Vouchers. The Department further received information indicating that the management company was told by the Licensee that those persons would not be subject to need for a Physician’s Report nor a Tuberculosis test. LPA met with Executive Director, Annemarie Domizio, for the purpose of gathering additional information.

Documents obtained:
  1. Copy Lease Agreement for 55+
  2. Copy Offer to Rent and Application Process
  3. Copy Pacifica S.D. Management Single Family Residence Rental Application


No citations are being issued on this date. 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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