019201182-7-25-2024-15-AS-KHOS-D8CHDR-20240821060645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:29:25 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
04/16/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240416120139

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:	01:45 PM

ALLEGATION(S):

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Licensee did not adhere to the terms and condition of Admission Agreement.

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.

During investigation, the Department obtained the following documents from the facility –residents’ rosters, Residence and Care Agreement California, Lake Park Resident Handbook (P. 29-31) and California-Nevada Methodist Homes (CNMH) "Lake Park" Care and Residence Agreement (Classic Agreement).

Allegation: Licensee did not adhere to the terms and condition of Admission Agreement.
Investigation 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 4

Control Number 15-AS-20240416120139

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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During the investigation, the Department conducted interviews with staff, residents & witnesses; and performed a review of records. On 04/19/2024 LPA interviewed Reporting Party (RP) who stated that Pacifica did not adhere to the Admission Agreement which states that the facility would maintain 24-hour a day Security Service. The RP further stated that facility vans had been vandalized in the parking lot, that there is no security at the front lobby door and no working security cameras on the premises. The Department further found that per the terms of sale, the CCRC contracts generated with residents under the previous owner would be adhered to by the new/current owners. The LPA observed that the agreement generated under the previous licensee provided that the Licensee “maintains a 24-hour emergency call system, a security entrance system, and security personnel.” The LPA further observed in the 2014 Lake Park Resident Handbook it is stated that “A security guard patrols the buildings and grounds on a regular basis…Lake Park’s security system includes secured entrance doors, camera monitoring of building entrances and parking areas, visitor identification, and 24-hour-a-day security guard service.”

On 04/23/2024 LPA interviewed S1, who stated that the previous private security company, Allied Security, was providing the security services a year ago. S1 stated that the current "security service" is performed by "in-house employees." S1 stated that the receptionist at the front desk is there for part of the 24hr security and that the overnight "awake caregivers" provide the security at night. S1 further stated that Allied Security had a station with phone numbers & computers; and were responsible for screening all persons before entering the facility, and for contacting the residents when their visitors arrived. S1 stated that there has not been dedicated security guard service due to non-payment of services rendered since the Spring of 2023. On the same day, the LPA interviewed S2, who stated that the security cameras are no longer operational due to non-payment of services – also since the Spring of 2023.

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 4

Control Number 15-AS-20240416120139

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 4/23/24, the LPA interviewed R1 and R2, who stated that per the contract generated by the previous Licensee, 24-hour a day security service was on site in the outer lobby area and that the only times a guard wasn’t at the station were during rounds. R1 further stated that shortly following the sale, the new owners had untrained persons serving as “security” stationed at reception; and that the outer front door had been “unlocked” and other persons had been able to access the facility due to the lack of security. On same day, LPA interviewed R3 who stated feeling unsafe; and interviewed R4, who also stated that vehicles in the parking lot had been vandalized & burglarized, that the front door had been unsecured, the garage door has not closed properly since September of 2023, and that resident safety is a concern. R4 also stated that before the sale, a security guard was present who would have to allow visitors access into the facility.

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 the facility is not adhering to existing CCRC contracts as required by the California Department of Justice per terms of sale to the current licensee – by removing the 24-hour security provided for in the CCRC contracts. 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 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)

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Control Number 15-AS-20240416120139

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 HSC 1793.2(s)	1 2 3 4 5 6 7	§1793.2(s) “…the Department, in its discretion, may condition, suspend, or revoke any…certificate of authority issued under this chapter if it finds that the applicant or provider has done any of the following: (s) Failed to fulfill his or her obligations under continuing care contracts.” This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC date, the facility will hire a dedicated 24-hour security service.
	8 9 10 11 12 13 14	Based on observations, interviews and record reviews, the licensee did not comply with the section cited above by not providing adequate 24-hour security as specified in existing CCRC contracts – with adherence to existing CCRC contracts being a condition of terms of sale by the California Department of Justice, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
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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 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)

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