019200529-7-16-2024-15-AS-KHOS-D84PXZ-20240813114309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200529
Report Date: 07/10/2024
Date Signed: 07/16/2024 10:51:41 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
07/02/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240702150218

FACILITY NAME:	LAKESIDE PARK		FACILITY NUMBER:	019200529
ADMINISTRATOR:	ESPINOZA, CHELSEA J		FACILITY TYPE:	740
ADDRESS:	468 PERKINS ST		TELEPHONE:	(510) 444-4684
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	76	CENSUS: 53	DATE:	07/10/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Jocelyn Fabros, Resident Care Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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1. Staff do not treat resident with respect
2. Night staff sleeping during work hours

INVESTIGATION FINDINGS:

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This is an amended report. On this day, 07/16/2024, Licensing Program Analyst (LPA), L. Alexander returned to correct the status of report to "PUBLIC."

On 07/10/2024, at 10:15 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct complaint investigation visit for the above allegations. LPA met with Resident Care Director, Jocelyn Fabros, and explained the reason for the visit. Executive Director, Grant Haywood, arrived shortly after.

LPA obtained and reviewed LIC 500, Resident Roster, Staff Schedules for July, NOC timesheets for July, and 6 (six) residents' files.

Allegation: Staff do not treat resident with respect.
Unsubstantiated.

On 07/10/2024 LPA interviewed Staff (S) S1-S4 and Resident (R) (R1) . It was alleged that staff is saying emabarassing things to the residents. S1 stated that they don't know of nor heard of any of the staff saying anything disrespectful or specifically telling a resident to "shut up." S2 stated that they have no knowledge of any staff being disrespectful to any residents on the floor. S3 stated that they have no knowledge of any staff being rude and disrespectfully. S3 stated that if they did hear of anyone saying anything disrespectful or telling R1 to "shut up" that they will not allow it. S4 stated that they have not heard of anyone saying or being disrespectful to any resident. S4 stated that they see the residents like their own parents and therefore would not allow anything like that to happen and not take action.

LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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-20240702150218

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKESIDE PARK	FACILITY NUMBER: 019200529
	VISIT DATE: 07/10/2024

NARRATIVE

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LIC9099-C Continued...

LPA interviewed R1 who was observed sitting in the common area amongst other residents watching television. S1 brought R1 over to a quiet area so that LPA Alexander could talk and ask R1 some questions. LPA observed that R1 was in a good mood, sharing some memories of family, military background, hometown and profession as a former educator and jazz musician. R1 stated that they are treated ok at the facility, and do not have any issues or concerns.

Allegation: Night staff sleeping during work hours
Unsubstantiated.

On 07/10/2024 LPA interviewed Staff (S) S1- S4. It was alleged that night staff is sleeping during work hours. S1 stated that the Night Shift (NOC) schedule is from 10pm to 6:15am and that they try to schedule two (2) Nayas "...person with wisdom and guidance..." (caregiver) to each floor and one (1) Med-Tech which end their shift at 6:30am. S1 stated that they have no knowledge of any NOC staff that is sleeping and not being attentive to the residents. S1 stated that Naya's are doing their rounds, checking on residents every hour, helping with the inventory and staying busy. S1 stated that they have had in-training regarding being alert, watching 1-2 of the residents that are wanderers, and staying woke and not sleeping while being on work duty.

S2 stated that they work during the day shift and generally they pass out medications. S2 stated that sometimes they will assist a resident to the bathroom if one of the Nayas is busy with another resident at that time. S2 stated that they have no knowledge of any of the staff sleeping during the NOC.

LIC9099-C (Page 2)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20240702150218

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKESIDE PARK	FACILITY NUMBER: 019200529
	VISIT DATE: 07/10/2024

NARRATIVE

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LIC9099-C Continued...

S3 stated that they have no knowledge of any staff at the facility sleeping and not being alert and awake during work hours.

S4 stated that they have no knowledge of any staff sleeping during the NOC shift and that also includes the evening shift that they currently work.

LPA L. Alexander asked S1 if any of the residents needed a two (2) person assist and S1 stated that there are a couple residents that need 2 person assist if they are in a wheelchair and need assistance. S1 stated that in this case another Naya would go and get another Naya to assist if needed.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC9099 (FAS) - (06/04)

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