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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:24:15 PM

Document Has Been Signed on 10/09/2024 04:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAKE PARK SENIOR LIVINGFACILITY NUMBER:
019201182
ADMINISTRATOR/
DIRECTOR:		KORFHAGE, KIRSTENFACILITY TYPE:
741
ADDRESS:1850 ALICE STREETTELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY: 275CENSUS: 94DATE:
10/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Kirsten Korfhage, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 10/09/2024 at 4:00 PM Licensing Program Analysts (LPAs) L. Alexander and D. Doidge arrived unannounced to conduct a Case Management visit. LPAs met with Executive Director (ED), Kirsten Korfhage.

While LPA L. Alexander and D. Doidge was conducting a complaint investigation (15-AS-20240811203347). LPA were informed back on 09/17/2024 that Northstar (management and Pacifica (ownership) did not have a surety bond. LPAs interviewed ED and asked if the facility holds the resident's cash. ED stated no and that residents may have a fiduciary or banker that manages their money.

No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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