<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:30:07 PM


Document Has Been Signed on 12/07/2022 02:30 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
E BAY DELTA AC/SC, 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: 114DATE:
12/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Candice Moses, Executive DirectorTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/7/2022 at 1:40PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management health & safety check and met with Tammy Hauck and the new Executive Director Candice Moses, and explained the purpose of the visit.

LPA was screened at the front entrance with routine COVID-19 symptom checks done by staff. Food, PPE, and other paper supplies are adequate, staffing is sufficient. Cough/sneeze etiquette and hand washing posters were observed posted in common areas and bathrooms.

Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards. LPA requested LIC 500, current assisted living staff schedule, nursing schedule, housekeeping staff schedule, maintenance staff schedule, and food service schedule submit to CCL by today.

LPA randomly interviewed 6 residents and 4 staff, residents stated that no changing is noticeable, service is remained the same. Staff stated that their work schedules are remained the same.

There was no imminent health/safety concerns on today's date.

Exit interview conducted with ED and a copy of this report provided by email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
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 1