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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:31:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2024 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20240129153841
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: 100DATE:
02/09/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Annemarie DomizioTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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On 2/9/2024 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility unannounced to deliver the finding concerning the allegation above. Upon entry, the LPA informed Business Office Manager (BOM) of the purpose of the visit. The BOM informed the Executive Director (ED) Annemarie Domizio by phone.

Allegation: Facility is in disrepair. – Substantiated
On 2/5/2024, the LPA observed that the security door at the front of the building and the security door into the building from the garage were propped

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED.

Deficiency is cited under the California Health and Safety Code listed on LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2024 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20240129153841

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: 100DATE:
02/09/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Annemarie DomizioTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Facility is unclean
Staff did not provide a safe environment for residents
INVESTIGATION FINDINGS:
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On 2/9/2024 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived at the facility unannounced to deliver the findings concerning the allegations above. Upon entry, the LPA informed Business Office Manager (BOM) of the purpose of the visit. The BOM informed the Executive Director (ED) Annemarie Domizio by phone.

Allegation: Facility is unclean - Unsubstantiated
On 2/2/2024 and 2/5/2024, the LPA interviewed Residents R1, R2, R3, and R5 who stated that the facility was unclean. On 2/5/2024 and 2/9/2024, the LPA toured the facility and found it to be clean.

Report Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20240129153841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
VISIT DATE: 02/09/2024
NARRATIVE
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... Report Continued from LIC9099

Allegation: Staff did not provide a safe environment for residents – Unsubstantiated
On 2/2/2024 and 2/5/2024, the LPA interviewed Residents R1, R2, R3, and R5 who stated that their safety concerns were related to the lack of security guards (as addressed in the 3/10/2023 complaint that was substantiated on 2/1/2024) and the non-operational security doors at the front of the building and in the basement already cited in this complaint. During the LPA’s tours of the facility on 2/5/2024 and 2/9/2024, there were no other safety violations identified by the LPA.

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted with ED. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20240129153841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
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The Licensee shall repair both the front and the basement doors on or before the due date.
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Based on observation and interviews, the Licensee had not repaired the front door for over a month and the basement door for more than four months, which poses a potential health and safety risk to residents 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) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5