019201182-2-16-2024-15-AS-KHOS-D93N38-20240913100556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 02/16/2024
Date Signed: 02/16/2024 05:36:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
02/15/2024 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240215100833

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: 100	DATE:	02/16/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Annemarie Domizio, Executive Director		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff does not ensure facility is equipped with restroom grab bars.
Staff does not ensure facility restrooms have toiletries.
Staff does not ensure facility restrooms are kept clean.

INVESTIGATION FINDINGS:

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On 2/16/2024 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility unannounced to conduct an initial 10-day complaint investigation visit concerning the allegations above. Upon entry, the LPA informed Business Office Manager (BOM) of the purpose of the visit. The BOM informed the Executive Director (ED) Annemarie Domizio.

Allegation: Staff does not ensure facility is equipped with restroom grab bars.
The LPA made observations and conducted interviews of staff and residents. Though there are not ADA-compliant grab bars currently in the public restrooms used by facility residents, the ED stated that there have been supply delays during the renovation and that by the end of February 2024 the updates will be complete.

Report Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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-20240215100833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LAKE PARK SENIOR LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 02/16/2024

NARRATIVE

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...Report Continued from LIC9099

Allegation: Staff does not ensure facility restrooms have toiletries.
LPA observed that the public restrooms used by facility residents did have toiletries.

Allegation: Staff does not ensure facility restrooms are kept clean.
LPA observed that the public restrooms used by facility residents did have toiletries.

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. Appeal Rights and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC9099 (FAS) - (06/04)

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