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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:53:44 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
04/05/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240405144954
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: 35DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Gaffar Syed, AdministratorTIME COMPLETED:
03:07 PM
ALLEGATION(S):
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Staff yell at resident
Staff do not follow residents care plan
Staff do not allow resident to receive visitors
Staff do not maintain facility is kept clean and free of odors
Staff do not provide resident with housekeeping service
Staff do not provide resident with toilet paper
Staff do not provide residents with activities
INVESTIGATION FINDINGS:
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On 12/17/24, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to 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 toured the facility, interviewed S1 and S2, four residents (R1, R2, R3 and R4). LPA also reviewed the care plans for R1, R2, R3 and R4, the facilities activity schedule and visitors’ policy.

Allegation: staff yell at resident
Three of the four residents interviewed (R2, R3 and R4) stated that the staff do not yell at them. All three stated that the staff were nice and that the staff were very helpful. R1 stated that S1 raises his voice when speaking to her. LPA has observed that S1 tends to speak in a louder than normal tone to the residents. S1 stated he does that because many of the resident are hard of hearing but denied raising his voice intentionally when speaking to R1. This allegation is unsubstantiated.
***report continues on LIC9099C***

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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-20240405144954
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: 12/17/2024
NARRATIVE
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***report continues from LIC9099***

Allegation: staff do not follow residents care plan

LPA reviewed R1, R2, R3 and R4’s care plans. LPA also interviewed R1, R2, R3 and R4. LPA asked about the care they are receiving at the facility and all 4 residents confirmed that they are receiving the care that is outlined in their care plans. This allegation is unsubstantiated.

Allegation: staff do not allow resident to receive visitors

Interview with S1 and S2 revealed that R1 was allowing visitors to come back to her bedroom without the facility staff even knowing that the visitors were in the building. R1 was using her cell phone to contact her visitors. On one occasion one of the visitors, a male, was seen lying on R1’s bed. The facility’s visitation policy states that visitors must wait in the lobby for staff to get the residents they wish to visit and the visit should take place in one of the common areas of the facility. Since all of the rooms are shared this policy ensures that the right to privacy of the roommate is protected. LPA also reviewed the visitation policy in the facility’s admission agreement, and it states that visitors should “wait in the lobby for staff assistance when visiting residents.” This allegation is unsubstantiated.

Allegation: staff do not maintain facility is kept clean and free of odors

LPA has been at this location on numerous occasions over the past three years. LPA has always observed the housekeeping staff to be very attentive and preforming their tasks to ensure the facility is clean and free of orders. LPA has never observed the facility to be dirty or smelly. S1 stated that they have 3 full-time housekeepers on duty from 7:00 AM to 7:00 PM. It should be noted that many of the residents are incontinent and sometimes have incontinence in the common areas of the facility. It is the experience of the LPA that staff are quick to clean up the mess. This allegation is unsubstantiated.

Allegation staff do not provide resident with housekeeping service

As stated above the facility has three full time housekeepers. During numerous visits to the facility LPA has observed the housekeepers preforming their work, i.e. sweeping, and mopping the floors, dusting surfaces, emptying trash cans, cleaning the residents' rooms, etc. They rotate throughout the facility to ensure the facility is kept clean. Residents’ bathrooms are cleaned on a rotating schedule. This allegation is unsubstantiated.

***report continues on LIC9099C***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240405144954
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: 12/17/2024
NARRATIVE
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***report continues from LIC9099C***

Allegation: staff do not provide resident with toilet paper

LPA observed toilet paper in R1's bedroom and bathroom as well as in her locked closet. LPA also observed toilet paper in several of the other bathrooms at the facility. S1 and S2 also stated they tell staff to check for toilet paper when they are working with the residents. This allegation unsubstantiated.

Allegation: staff do not provide residents with activities

LPA reviewed the facilities activity schedule and observed that there were several activities each day for the residents to participate in. LPA also observed that the activities occurring match what is listed on the activity schedule. During LPA's interview with R1 she stated that she doesn't like to participate in the activities at the facility because she doesn't like interacting with the other residents. R1 prefers to stay in her room and read, exercise and journal. This allegation is unsubstantiated.

This agency has investigated the allegations above. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3