019201182-7-25-2024-15-AS-KHOS-D84NPU-20240813103855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:23:41 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
04/02/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240402175048

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: 92	DATE:	07/25/2024
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Kirsten Korfhage, Executive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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The facility has changed the plan of operation without CCLD approval.

INVESTIGATION FINDINGS:

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On 07/25/2024 at 9:50 AM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Kirsten Korfhage to deliver findings of above allegation. LPA explained the purpose of the visit with Executive Director.

Allegation: The facility has changed the Plan of Operation without Community Care Licensing Division (CCLD) approval.
Finding: Substantiated

LIC9099-C Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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

Control Number 15-AS-20240402175048

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 07/25/2024

NARRATIVE

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On 3/28/24, the agency was informed by senior staff of the facility that the plan of operation had been changed and that it would be leasing units to independent renters who are age 55 and above, and to Section 8 recipients. During the investigation, the Department conducted interviews with staff, clients, witnesses, and reviewed records. LPA interviewed the Reporting Party (RP) who again stated that the Licensee instructed staff that the facility will start leasing apartments in the facility to 55+ independent residential renters, as well as to Section 8 recipients; and that these renters would not be subject to RCFE requirements to obtain current Physician Reports, Tuberculosis testing nor Background Clearance checks as residents outside of RCFE services. The RP further stated that these units will be leased on floors with existing residents who were admitted under Residential Care for Elderly (RCFE) and/or Continuing Care Retirement Community (CCRC) contracts. LPA reviewed the Northstar Senior Living, Inc. Assisted Living & Memory Care Program Outline (Plan of Operation) that was submitted to CCLD as part of their licensing application. The Department observed that there is no language or provision indicating that the Plan of Operation would, or possibly at a future date, the Licensee would consider operating with units for 55+ independent residents, nor Section 8 recipients.

On 04/08/2024 LPA reviewed a written statement by W1, indicating that W1 had become aware of plans for the facility to begin leasing units to 55+ independent individuals; and that these persons will have access to common areas and the fitness center; and that these persons would not be subject to having a Physician’s Report nor a negative Tuberculosis test prior to moving into the facility. Per the LPAs review of the Licensee’s Plan of Operation, it affirms that the necessary residency forms include a Physician’s Report and Tuberculosis test, which the Executive Director would obtain from all prospective residents.

LIC9099-C (Page 2)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20240402175048

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 07/25/2024

NARRATIVE

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On 04/09/2024 LPA interviewed S4 who stated that the direction to change the Plan of Operation came from the owner and that facility staff do not communicate directly with the owner, but rather with other executive management. S4 further stated that S2 was interviewed and selected directly by the Licensee’s executive management staff to manage the leasing of units to 55+ independent persons; and that marketing for 55+ has been published on two housing rental websites.

On 4/9/24, LPA interviewed S2 who stated having begun working at the site approximately 3 weeks prior. S2 stated that the 55+ rentals would be on the 2^nd and 6^th floors – which the Department observes to be areas licensed by CCLD.

On 4/25/24, LPA obtained and reviewed the document, “Proposed Sale of the Assets of California-Nevada Methodist Homes,” generated between the State of California Department of Justice and the current Licensee, dated January 7, 2020; and observed that it states, “All entities listed in Condition I shall fulfill the terms of these agreements (and)… shall notify the Attorney General in writing of any proposed modification or rescission on any terms of these agreements.” No evidence was found that showed that the Licensee communicated with the Attorney General prior to changing their Plan of Operation.

On 06/27/2024, LPA obtained and reviewed a copy of the current admission agreement, "Residence and Services Agreement," and observed that it combines general renter language with standard RCFE language.

On 7/15/24, LPA found that the facility’s website is advertising as featuring a “55+ independent living” component.

LIC9099-C (Page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20240402175048

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 07/25/2024

NARRATIVE

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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, and the Department has determined that a significant change to the plan of operation affecting the services of residents has been enacted without the approval of the Agency. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Failure to correct deficiencies by POC due date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

LIC9099-C (Page 4)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20240402175048

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 019201182
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/15/2024 Section Cited CCR 87208	1 2 3 4 5 6 7	“…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC date, the facility will submit to CCLD for review a new, detailed plan of operation describing the changes that the Licensee wishes to implement.
	8 9 10 11 12 13 14	Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5