019201182-4-15-2024-15-AS-BFOG-D6TMLD-20240703094207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 04/15/2024
Date Signed: 04/15/2024 12:42:47 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
04/05/2024 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20240405164105

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: 105	DATE:	04/15/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Annemarie Domizio, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility has pests.

INVESTIGATION FINDINGS:

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On 04/15/2024 at approximately 9:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an initial 10-day complaint investigation visit regarding the allegation above. LPA met with Executive Director (ED), Annemarie Domizio, and explained the purpose for the visit.

During the course of investigation LPA interviewed staff. S1 stated there are pests in the kitchen, but the issue has been addressed. Clark Pests Control company (Clark) came out on 4/9/24 to conduct an assessment on the issue. LPA observed that there are multiple traps are places around the kitchen areas. S1 stated Clark have not been out since January, however as of last week Clark started to come and check on the pests’ issue. S1 have seen a better improvement after Clark came out. According to S1 after Clark did their assessment, they stated that there a process that need to be done, so they recommended that they need to be at the facility weekly to eliminate the ongoing pest’s issue. S1 spoke to ED regrading Clark recommendation, and ED agreed/approved with Clark recommendation.

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 and copy of this report provided via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

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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