015601408-4-23-2026-15-AS-GLUK-DXB32U-20260825175228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 04/23/2026
Date Signed: 04/23/2026 04:22:55 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
02/23/2026 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20260223165309

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: 34	DATE:	04/23/2026
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Gaffar Syed, Administrator		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Resident fell and sustained broken ribs from staff neglect

Facility did not address bed bug issues.

Facility mismanaged resident's medications.

INVESTIGATION FINDINGS:

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On 4/23/2026 at 1:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to continue the complaint investigation and deliver complaint findings for the allegations above. LPA met with Gaffar Syed, Administrator and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff (S1, S2, S3, and S4), witnesses, obtained and reviewed records.

Allegation: Resident fell and sustained broken ribs from staff neglect

During initial interview W1 reported fall was possibly caused by another resident and/or care neglect from the facility. S1 stated he was not at the

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

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-20260223165309

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: 04/23/2026

NARRATIVE

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Continued from LIC9099.

facility at the time of the incident, however, he received a call from S3. S3 stated during interview that she did not witness the fall, but was called to come assist when it occurred. S3 observed R1 down on the floor near the piano. S4 stated she witnessed R1 fall and hit either her back or side on the corner of the table. Both (S3 and S4), stated R1 was placed in a chair, R1 stated she was in pain, and 9-1-1 was called. S2 stated during interview that R1 had not fallen before. R1 could not be interviewed due to the diagnosis. LPA reviewed R1's physician report dated 5/29/2025, which indicated R1 did not have any motor impairment and was ambulatory.

Allegation: Facility did not address bed bug issues.

During interview it was reported by W2 that R1's room had bed bugs in 2024 and R1 was moved to another room. W1 stated during interview that the facility took care of "that issue" and the allegation should not be addressed. S2 stated there is no bed bugs at the facility. LPA reviewed complaints and case management visits back to 2023 and did not observe any case of bed bugs. As of today's date the facility do not have a bed bug issue.

Allegation: Facility mismanaged resident's medications.

During interview W2 reported when R1 first moved to the facility she was active until the additional medication was given. W1 stated the medication was documented each time R1 was given medication and doesn't feel it was mismanaged. LPA reviewed the medication administration record (MAR) for January and February 2026, and observed each day R1 was at the facility it

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20260223165309

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: 04/23/2026

NARRATIVE

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Continued from LIC9099C.

was documented the medication was given as directed. S2 stated she administers the medication. S2 recalled sometimes R1 would refuse medication, S2 would wait for a little while and go back, and R1 would take the medication.

Based upon the information obtained and the interviews conducted during the investigation, the above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3