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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 09/15/2022
Date Signed: 09/23/2022 03:54:29 PM


Document Has Been Signed on 09/23/2022 03:54 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
CCLD Regional Office, 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: DATE:
09/15/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Deepak Israni, Carl KneplerTIME COMPLETED:
02:00 PM
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On 9/15/22 at 1:30 pm, a virtual meeting was conducted pertaining to the licensure (application pending) for Lake Park Senior Living and Pacific Grove Senior Living. Participants in the meeting included:
  • Pam Gill, Assistant Program Administrator, CCLD
  • Stacy Barlow, Assistant Program Administrator, CCLD
  • Isaac Taggart, Regional Manager, CCLD
  • Brenda White, Regional Manager, CCLD
  • Jeremy Fong, Licensing Program Manager, CCLD
  • Allison Nakatomi, Staff Services Manager for Continuing Care Retirement Care, CCLD
  • Shawna Doucette, Licensing Program Analyst, CCLD
  • Deepak Israni, President & Managing Partner, Pacifica Senior Living
  • Carl Knepler, Senior Vice President of Operations, Pacifica Senior Living
  • Marlene Nelson, Pacifica Senior Living
  • John Peters, Northstar
  • Tammy Hauck, Northstar

CCLD reviewed the following expectations for Pacifica Senior Living and Northstar (hereinafter referred to as "applicants"):
  • Identify an individual who will serve as Corporate Liason and be responsible for reviewing all licensing reports, report to the Board of Directors the status of corrections, and conduct quarterly quality assurance audits of both facilities.
  • Ensure sufficient staffing at the facility to the extent that each memory care unit will be staffed independently, and that units do not share direct care staff.
  • Ensure that the facility has adequate oversight by a qualified facility administrator during normal working hours at a minimum of 40 hours per week.
SUPERVISOR'S NAME: Pam GillTELEPHONE: (510) 286-4352
LICENSING EVALUATOR NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
VISIT DATE: 09/15/2022
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Assistant Program Administrator (APA) Pam Gill explained that the Department may conduct increased inspections for monitoring purposes. The applicant agreed to each of the listed conditions.

A copy of this report was reviewed with Pacifica Senior Living and sent by email for signature. A fully signed copy of this report was provided to Pacifica Senior Living and placed into the facility file.
SUPERVISOR'S NAME: Pam GillTELEPHONE: (510) 286-4352
LICENSING EVALUATOR NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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