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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601408
Report Date: 09/05/2025
Date Signed: 09/05/2025 02:26:23 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
08/28/2025 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20250828142143
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: 33DATE:
09/05/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Gaffar Syed, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are mishandling a resident's medication
INVESTIGATION FINDINGS:
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On 9/05/25 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver filings in regard to the above allegation. LPA met with Gaffar Syed, Administrator, and explained the purpose of the visit.

During the course of the investigation LPA interviewed W1, S1 and R1, reviewed R1’s file and medications.

LPA corresponded with W1 via email. W1 would only say that a participant at the program where she works complained that the facility where he lives was miss-managing his medication. W1 would not provide LPA with the name of the participant.

***report continues on LIC9099C***

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

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
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 2
Control Number 15-AS-20250828142143
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: 09/05/2025
NARRATIVE
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***report continues from LIC9099***


LPA interviewed S1 at the facility. S1 identified the individual in question as R1 and was well aware of R1's complaint. R1 does attend the program where W1 works and often complains about not getting enough medication. S1 stated that R1 is on a controlled medication so the facility must take extra steps to safeguard it. LPA reviewed medication administration records and compared them with the bubble packed medication. LPA found no discrepancies.

LPA interviewed R1 via phone as he was at his program. R1 said he liked living at the facility. LPA asked about his medication and R1 replied “they don’t give me enough.”

This agency has investigated the above complaint. 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: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2