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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 10/24/2023
Date Signed: 10/24/2023 04:07:59 PM


Document Has Been Signed on 10/24/2023 04:07 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: 109DATE:
10/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:43 PM
MET WITH:Annmarie Dominici, Executive DirectorTIME COMPLETED:
04:10 PM
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On 10/24/23 at 3:43PM, while at the facility for another reason, Licensing Program Analyst (LPA) toured the facility with executive director (ED) who stated that since the original structural and electrical configurations remained the same, no construction permits were required. ED shared a copy of facility sketch with LPA during visit (see 812 for details).

ED stated that remodelled areas were sectioned off to ensure residents are not impacted by the renovations. ED stated they secured a permit for the new bathroom tiles (see 812 for more details). LPA observed new flooring, paint, furnitures and fixtures on the first, second and 12th floors. LPA observed facility to be clean, bright and in good repair.

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: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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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