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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 02/24/2023
Date Signed: 02/24/2023 11:55:00 AM


Document Has Been Signed on 02/24/2023 11:55 AM - 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: 98DATE:
02/24/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Candice Moses, Executive DirectorTIME COMPLETED:
12:00 PM
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On 02/24/23 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management health & safety check and met with executive director (ED). LPA explained the purpose of the visit with ED.

LPA was screened at the front entrance with routine COVID-19 symptom checks done by staff. LPA toured the facility with ED. LPA observed facility is currently undergoing renovations in the library and visitation areas. LPA observed temporary wall erected in the hallway to ensure remodeling activities are contained within and residents are not impacted by the remodelling. ED stated the building is old and areas have been identified for renovations and improvements. LPA observed the kitchen had sufficient food supplies. Food supplies are ordered & delivered weekly. LPA also observed adequate supply of PPEs in the kitchen cabinets/storage areas. LPA observed bathrooms has sufficient soap and paper towel supplies. LPA observed dining area has been expanded to include a cafe area for breakfast and hot meals are served by staff in the dining hall for residents. ED stated residents have the option to have food to go or meal trays delivered to their respective apartments.

Sufficient staffing was observed during visit. Pathways and hallways were observed free of obstruction and fire hazards. Comfortable temperature was maintained at 72 degrees Fahrenheit. LPA observed residents clean, well-groomed and comfortable in their surroundings. LPA obtained documents (current employee roster, assisted living staff schedule, housekeeping staff schedule, and maintenance staff schedule) during visit.

Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during inspection.
Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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