<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:31:21 PM


Document Has Been Signed on 06/21/2024 04:31 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: 89DATE:
06/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Kirsten Korfhage, Executive DirectorTIME COMPLETED:
04:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/21/2024 at 3:00 PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, Kirsten Korfhage.

While LPA L. Alexander was conducting a complaint investigation (15-AS-20240619101457) on 06/21/2024. LPA was informed that the food availability was questionable for the residents back on 05/26/2024. During the complaint visit, LPA observed that there was adequate food available. Therefore the food guest services is adequate for the residents.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1