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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 06/29/2021
Date Signed: 06/29/2021 12:50:38 PM



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
06/24/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210624164037
FACILITY NAME:LAKESHORE RESIDENTIAL CAREFACILITY NUMBER:
015601408
ADMINISTRATOR:SYED, GAFFARFACILITY TYPE:
740
ADDRESS:1901 THIRD AVENUETELEPHONE:
(510) 834-9880
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:38CENSUS: 34DATE:
06/29/2021
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Gaffar Sayed/AdministratorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Unlawful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo r arrived unannounced to investigate the above allegation. LPA met with Gaffar Syed, administrator. LPA informed the purpose of visit. Noria Saleh, co-administrator, arrived after about an hour.

It was alleged that resident (R1) is new to the facility and was having hard time adjusting. R1 was sent out to the hospital and when ready to be discharged, facillity refused to admit R1 back.

LPA obtained copy of LIC9020 resident roster. LPA reviewed R1's record and obtained copies of following documents: Admission Record; LIC602A Physician's Report; Individual Service Plan; LIC624 Unusual Incident/Injury Report. R1 is still not at the facility on this day, June 29, 2021.

.......continued next page (9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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-20210624164037
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: LAKESHORE RESIDENTIAL CARE
FACILITY NUMBER: 015601408
VISIT DATE: 06/29/2021
NARRATIVE
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LPA interviewed S1 who stated R1 has been in the facility for few hours and had behaviors. Gaffar Syed and Noria Saleh both indicated R1 was admitted on June 23, 2021, has been in the facility for few hours and exhibited behaviors and a threat to herself. R1 was sent out to the hospital. The hospital called same day on June 23rd indicating R1 was stabilized and ready to be discharged that night. Noria stated she told the hospital's social worker that R1 needs to be send out to a psychiatric ward to be evaluated prior to discharging back to the facility. R1 and/or R1's responsible person was not given a notice of eviction.

Based on information obtained and review of records which revealed R1 does not have psychiatric diagnosis to warrant a need for R1 to be transferred to psychiatric ward prior to admitting R1 back and for not giving an eviction notice, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date along with LIC9098 Proof of Correction form and any repeat violation within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with Gaffar Syed and Noria Saleh.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20210624164037
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: LAKESHORE RESIDENTIAL CARE
FACILITY NUMBER: 015601408
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2021
Section Cited
CCR
87224(b)
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87224 Eviction Procedures
(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit.

This requirement is not met as evidenced by:
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Administrator and co-administrator to do the following:
1. Read the Regulations and follow the eviction procedure when necessary and submit self-certification to be submitted.
2. In service the staff on proper redirecting.
Copy of in-servive training and self-certification to be submitted by 7/13/2021.
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-Based on interviews and records review, the licensee did not comply with the Regulation above by not admitting resident back and did not provide the resident and resident's responsible person an eviction notice which posed potential personal rights risk to person in care,
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3