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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 04/11/2024
Date Signed: 04/11/2024 05:01:54 PM


Document Has Been Signed on 04/11/2024 05:01 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:
04/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Annemarie Domizio, Executive DirectorTIME COMPLETED:
05:20 PM
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On 4/11/2024 at 2:00PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a POC (Proof of Correction) visit. LPA met with Executive Director (ED), Annemarie Domizio, and informed the reason for the visit.

LPA and ED went over the deficiency, the POC and the current billing and payment status for PG&E and Waste Management accounts.


The following deficiencies were cleared by visit:

87755(b) - ED identified PG&E and Waste Management accounts are current and paid up through March 2024.


Exit interview conducted. A copy of this report and Letter of Deficiency Citations Cleared provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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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