019201182-7-18-2023-15-AS-KHOS-CU9LGG-20230731084444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 07/18/2023
Date Signed: 07/18/2023 11:19:45 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/30/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230130144957

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:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	11:02 AM
MET WITH:	Annemarie Domizio, Executive Director		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Facility is in disrepair
Facility failed to provide appropriate transportation
Facility failed to provide nutrition food service to meet resident's needs
Facility failed to provide a comfortable temperature
Facility failed to adhere to residents' admission agreement

INVESTIGATION FINDINGS:

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On 07/18/23 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

Allegation: Facility is in disrepair
Investigation Finding: Unsubstantiated
During investigation, LPA C Lin confirmed with staff (ADM) that out of the three (3) elevators at the facility, one elevator has been broken since November 2022. ADM stated the other 2 elevators were working fine for residents’ use. ADM stated a request to replace the entire elevator system has been submitted for corporate approval. During case management visits, LPA D Panlilio observed two (2) elevators were operational on 12/07/22, 12/21/22, 02/24/23 for residents, staff and visitors to use in getting to different floors at the building. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility is in disrepair is unsubstantiated.
Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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 3

Control Number 15-AS-20230130144957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/18/2023

NARRATIVE

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Allegation: Facility failed to provide appropriate transportation
Investigation Finding: Unsubstantiated
During investigation, LPA C. Lin observed there are 3 vehicles including 2 buses. Only 1 bus has a lift which would constantly break down and get fixed by staff. Administrator (ADM) stated that scheduled transportations are made available for residents to use for their medical and dental appointments. ADM stated that other transportation options outside normal business hours may be arranged by the resident with staff (Activities Director) for an additional charge or with an outside agency if necessary. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility failed to provide appropriate transportation is unsubstantiated.

Allegation: Facility failed to provide nutrition food service to meet resident’s needs

During investigation, staff (ADM) stated all meals daily prepared by the facility for breakfast, lunch and dinner follow the nutritional guidelines created from a nutrition company. ADM stated all residents were provided the nutritional guidelines. On 12/21/22 and 02/24/23, LPA observed a bulletin board of special diets located in the kitchen area that staff follow to prepare residents’ special diets as prescribed by their primary care physicians. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility failed to provide nutrition food service to meet residents’ needs is unsubstantiated.

Allegation: Facility failed to provide a comfortable temperature

Investigation Finding: Unsubstantiated
During investigation, resident (R1) confirmed with LPA C Lin that their thermostat was hard to adjust and remained at 80 deg F. Staff (ADM) stated the water pump has been repaired in January 2023 and the temperature is back to normal. ADM provided the receipt to LPA during visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility failed to provide comfortable temperature is unsubstantiated.
Continued on next page, LIC 9099-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230130144957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/18/2023

NARRATIVE

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Allegation: Facility failed to adhere to residents’ admission agreement
Investigation Finding: Unsubstantiated
During investigation, resident (R1) confirmed with LPA C Lin that the previous owner always provided meal options to meet residents’ needs as part of their contract. R1 stated that they used to have 2 main courses of 2 different meats, such as pork or beef and two main courses for vegetarian, one of them with less sodium that they can choose from a buffet style setting in the dining area. R1 stated that when new management took over in late December 2022, the dining buffet set-up was changed to restaurant style setting with staff delivering the food to their table. ADM stated the old contract for meals has not changed. Low sodium food is still available for residents who are served three (3) nutritionally balanced meals and snacks daily, delivered restaurant style to the resident’s table by staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility failed to adhere to residents’ admission agreement is unsubstantiated.

Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

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