015601408-7-5-2024-15-AS-KHOS-D9MPDC-20241001111315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 07/05/2024
Date Signed: 07/05/2024 12:25:08 PM

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
06/25/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240625163122

FACILITY NAME:	LAKESHORE RESIDENTIAL CARE		FACILITY NUMBER:	015601408
ADMINISTRATOR:	SYED, GAFFAR		FACILITY TYPE:	740
ADDRESS:	1901 THIRD AVENUE		TELEPHONE:	(510) 834-9880
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94606
CAPACITY:	38	CENSUS: 37	DATE:	07/05/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Gaffar Syed, Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff do not accord resident privacy.
Staff do not ensure resident's shower is in good repair.

INVESTIGATION FINDINGS:

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On 7/05/2024 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit.

During the course of the investigation LPA interviewed the R1, S1 and S2. LPA also toured the shower room.

Allegation: Staff do not accord resident privacy
The R1 states that other facility residents wonder into her room “all day long.” The facility has many residents with dementia. S1 states the staff do their best to redirect residents to ensure that R1’s privacy is protected. LPA interviewed R1 in R1’s room for approximately an hour no other residents wondered into her room. R1 further stated that she closes her door more often and that helps.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240625163122

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: 07/05/2024

NARRATIVE

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***report continues from LIC9099***

Allegation: staff do not ensure resident’s shower is in good repair.

LPA toured the shower room with S1. LPA observed that there are three separate shower heads in the shower room. All three were in operating condition during the visit. R1 has a staff assisted shower. LPA interviewed S2 who assists R1 with her showers. S2 confirmed that there was issue with the shower hose being twisted which caused the water to stop flowing momentarily. S2 untwisted the hose and continued with the shower.

This agency has investigated the complaint alleging staff do not accord resident privacy and staff do not ensure resident’s shower is in good repair. We have found that the complaints were unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

LIC9099 (FAS) - (06/04)

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