019201182-5-29-2024-15-AS-BFOG-D5XS3S-20240605133137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:43:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/21/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240521083323

FACILITY NAME:	LAKE PARK SENIOR LIVING		FACILITY NUMBER:	019201182
ADMINISTRATOR:	MEDINI, ROZA		FACILITY TYPE:	741
ADDRESS:	1850 ALICE STREET		TELEPHONE:	(510) 835-5511
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94612
CAPACITY:	275	CENSUS: 17	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Annemarie Domizio/Executive Director and Aryanna Henry/Business Office Manager		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff did not adhere to resident's admissions agreement.

INVESTIGATION FINDINGS:

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On this day, 5/29/2024, at 12:20 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Annemarie Domizio, and informed the reason for visit. LPA also met with Business Office Manager (BOM) Aryanna Henry.

It was alleged that the refrigerator in the unit broke and could not be fixed. The facility tried the older units but also failed and the facility declined to purchase a new one when the contract (Admission Agreement) clearly states that the units will have appliances.

During investigation. LPA obtained copies of resident roster and Admission Agreements. From the roster, LPA selected 5 residents for interview.

....continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240521083323

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKE PARK SENIOR LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 05/29/2024

NARRATIVE

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Admission Agreement submitted to the Department which was approved upon granting of license was reviewed by LPA. Item C of the Admission Agreement under Basic Services indicated in part “The Community will furnish the Apartment with carpeting and/or floor coverings, blinds, paint and/or wall covering on all interior walls and ceilings, convenience kitchen and/or kitchenette appliances, and heating and air conditioning. The Community shall have the sole and exclusive right to determine and select the type, style, design and color of each and every one of the foregoing items. Unless the Resident notifies the Community in writing of any alleged defect in the Apartment prior to the commencement of the Term, the Resident shall be deemed to have accepted the Apartment in an "as is'' condition.” The Admission Agreement also states under item E. Maintenance “The Community shall provide service and repairs for normal wear and tear to electrical and mechanical equipment provided with the Apartment. The Community will impose a charge to the Resident for the cost of replacement or repair of any such equipment that is caused by the Resident's neglect or willful act.

Four (4) out of 5 residents interviewed stated there's refrigerator in their room/unit when they moved-in and didn't have problem with it, The other resident stated the refrigerator was not working when this resident moved-in but the staff replaced it immediately without charge. LPA inspected the refrigerators in the 5 residents' rooms/unit which were observed in operating condition.

Based on information gathered, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

ED left the facility and BOM stated she can sign and receive this report.

Exit interview conducted, and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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