019201182-11-22-2024-15-AS-YFLS-DBD2EM-20241125162010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 11/22/2024
Date Signed: 11/22/2024 01:19:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
05/03/2024 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20240503094454

FACILITY NAME:	LAKE PARK SENIOR LIVING		FACILITY NUMBER:	019201182
ADMINISTRATOR:	MEDINI, ROZA		FACILITY TYPE:	741
ADDRESS:	1850 ALICE STREET		TELEPHONE:	(510) 835-5511
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94612
CAPACITY:	275	CENSUS: 97	DATE:	11/22/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director, Kirsten Korfhage		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff interfering with designation of responsible person for resident.

INVESTIGATION FINDINGS:

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On 11/22/2024 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegation. LPA met with Executive Director (ED), Kirsten Korfhage and explained the purpose of the visit.

LPA conducted a complaint investigation in relation to the allegation of "staff interfering with the designation of a responsible person for the resident." During the course of the investigation, LPA reviewed various records, conducted interviews, and obtained additional documents to fully understand the situation and to determine whether the allegation was substantiated.

Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240503094454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKE PARK SENIOR LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 11/22/2024

NARRATIVE

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continued from LIC-9099

On 5/03/2024, LPA conducted an initial visit where they conducted interviews and record review. LPA reviewed R1’s Admissions Agreement, which indicated that R1 was admitted to the facility as an independent resident on 1/10/2018. LPA also reviewed physician reports, including a previous report from 12/6/2017 that stated R1 was fully independent, as well as a report dated 3/27/2024, which showed R1 had been diagnosed with dementia and experienced confusion and memory loss.

During the investigation, LPA observed that R1 was initially in charge of their own affairs and had an emergency contact listed. However, through interview with previous ED and review of email correspondences LPA found that as concerns regarding R1’s cognitive decline arose, the previous ED contacted the emergency contact (W2) and R1’s Financial Advisor (W3) for guidance on 3/4/2024. The previous ED explained that, based on their observations of R1’s deteriorating condition, they reached out to W3 who is R1's financial advisor to express concerns about R1’s cognitive abilities and the potential risks to R1’s well-being. Previous ED was advised to contact R1’s attorney (W4) for POA information but previous ED never was able to reach W4 before they found out about the new POA. In the time while previous ED was trying to get in contact with W4, W2 took R1 to get a new physicians report. The previous ED stated that they followed the chain of contact, as outlined in R1's original documents, which specified the first emergency contact in case of concern. LPA reviewed and confirmed that based on R1’s emergency contact sheet the previous ED contacted the appropriate person. According to the original Emergency contact sheet W2 was designated as first person to be contacted for R1. The updated Emergency Contact sheet from 3/13/2024 still had W2 listed as the first point of contact for R1.

Report continues on LIC-9099C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240503094454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKE PARK SENIOR LIVING	FACILITY NUMBER: 019201182
	VISIT DATE: 11/22/2024

NARRATIVE

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continued from LIC-9099C

The previous ED explained that after making the necessary contacts, including with R1's emergency contact W2 and financial advisor W3, an unrelated individual, referred to as W1, became involved and was designated as R1's medical POA on 3/8/2024. The previous ED expressed concern that this individual, who was not previously known to the facility or listed in R1’s documentation, could be potentially taking advantage of R1. The previous ED also contacted W2 3/14/2024 R1's emergency contact to discuss the situation further. Subsequently, R1 was taken for a medical evaluation on 3/27/2024, where it was confirmed that R1 had dementia and was unable to manage medications, leave unassisted, or access grooming items.

LPA reviewed the visitor log for 3/8/2024, which showed that a notary signed in to visit R1, the same day W1 was listed the new POA, although there was no sign in for W1. The previous ED stated that their concern was that, due to the involvement of an individual who was not previously known to the facility and who was unrelated to R1, there was a potential risk of R1 being exploited. However, the previous ED adhered to the appropriate procedure by contacting R1’s emergency contact, as indicated in R1's original documentation, and did not interfere with the POA designation.

Although there were concerns about R1’s cognitive decline and the involvement of an unknown individual, there is insufficient evidence to support the allegation that staff interfered with the designation of a responsible person for the resident. The previous ED followed the appropriate steps, as outlined by the documents approved by R1, and contacted the correct parties in response to the concerns raised. Therefore, the allegation of “staff interfering with the designation of a responsible person for the resident” is 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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC9099 (FAS) - (06/04)

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