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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 11/08/2024
Date Signed: 12/29/2025 01:12:45 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
10/30/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20241030085123
FACILITY NAME:LAKE PARK SENIOR LIVINGFACILITY NUMBER:
019201182
ADMINISTRATOR:KORFHAGE, KIRSTENFACILITY TYPE:
741
ADDRESS:1850 ALICE STREETTELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 221DATE:
11/08/2024
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Fouzia Yaagoub/Business Office ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility is overcharging resident.
INVESTIGATION FINDINGS:
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 *THIS IS AN AMENDMENT OF REPORT DATED 11/08/2024*
At 10:55 am, Licensing Program Analysts (LPAs) A. Delmundo and D. Doidge arrived unannounced to investigate the above allegation. LPAs met with Business Office Manager (BOM) Fouzia Yaagoub and informed the reason for visit.

It was alleged that resident (R1) was charged $250.00 late payment charge and $50.00 for no sufficient fund (NSF). The $250.00 was reversed but not the $50.00.

LPAs interviewed BOM who confirmed the $250.00 was reversed but not the $50.00. BOM stated she communicated with their corporate office and was told that they are not reversing the $50.00 because the facility was charged by the bank for NSF.

.....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
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-20241030085123
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: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
VISIT DATE: 11/08/2024
NARRATIVE
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LPAs interviewed R1 who stated R1 has sufficient fund in R1's account and there's nothing showing R1 was charged by the bank for NSF. LPAs reviewed R1's bank statements which showed R1 issued check for 2 months rent for June 2024 and July 2024 and had an automatic payment deducted from R1's account on July 8, 2024. Lake Park returned the one month payment on July 3, 2024 and charged R1 for $50.00 for NSF.

Based on interviews and records review, the preponderance of evidence is met, therefore, the allegation is unsubstantiated. An unsubstantiated findings mean that although the allegation may have happened or is valid there is not a preponderance of evidence that the violation occurred.

No Deficiencies cited.

Exit interview conducted. Copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20241030085123
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: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/22/2024
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, .....residents in privately operated residential care facilities for the elderly shall have all of the following personal rights....
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***
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No dificiency cited
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3