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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:15:59 PM


Document Has Been Signed on 04/09/2024 03:15 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: 105DATE:
04/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Annemarie Domizio, Executive DirectorTIME COMPLETED:
03:30 PM
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On 04/09/2024 starting at 1:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted a Case Management while at the facility for another matter. LPA met with Executive Director (ED), Annemarie Domizio, and explained the purpose of visit.

During a complaint investigation (#15-AS-20240220153014) on 02/21/2024, LPA interviewed Staff and obtained the following documents:

1. Copy of invoices for non-payment for caregiver services
2. Copy of collection notice for caregiver services dated March 21, 2024
3. Copy of account ledgers for DIRECTV and Clark Pest Control
4. Copy of invoices for non-payment for DIRECTV and Clark Pest Control

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: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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