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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:24:31 PM

Substantiated


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
08/11/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240811203347
FACILITY NAME:LAKE PARK SENIOR LIVINGFACILITY NUMBER:
019201182
ADMINISTRATOR:MEDINI, ROZAFACILITY TYPE:
741
ADDRESS:1850 ALICE STREETTELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 97DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kirsten Korfhage, Executive DirectorTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility staff are inadequately trained

Facility has insufficient staffing
INVESTIGATION FINDINGS:
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On 12/04/2024 at 2:00 PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with Executive Director, Kirsten Korfhage and explained to her the reason for the visit.

During the course of the investigation, the Department conducted interviews with residents, staff, and witnesses. The Department obtained and reviewed the facility & staff roster, staff schedule and staff trainings. LPAs also reviewed a sample of resident’s re-appraisal and Physicians Reports.

Allegation: Facility staff are inadequately trained
Investigation Finding: Substantiated
It was reported to the Department that the facility staff has insufficient training hours.

continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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 5
Control Number 15-AS-20240811203347
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: 12/04/2024
NARRATIVE
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continue from LIC 9099

The department conducted interviews and reviewed training documents which reveal that several staff are insufficient in required training's which provides knowledge and skills needed to provide the care and needs of the residents. Therefore, this allegation is Substantiated.

Allegation: Facility has insufficient staffing
Investigation Finding: Substantiated

It was reported to the Department that the facility is short staffed during NOC shift. Review of staff schedules and interview with staff and residents revealed that there is 1 caregiver and 1 medication technician on staff during NOC shift. Interviews with residents also revealed that there are residents which require two persons transfer which would leave no staff available if staff had to attend to one of the other residents. Therefore, this allegation is Substantiated.

Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.



Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240811203347
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: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2025
Section Cited
CCR
87411(d)
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(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or rel...ing, as appropriate for the job assigned and as evidenced by safe and effective job performance:

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Administrator will ensure all AL staff training's are current and up to date and submit proof to CCL by POC date.
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This requirement is not met as evidenced by:

Based on interviews and file reviews, the licensee did not comply with the section cited above in not ensuring staff training's are current which poses an immediate health and safety risk to persons in care.
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Type B
01/06/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....Additional staff shall be employed as necessary to perform office work,...buildings..... and grounds......
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Executive Director (ED) to ensure sufficient staffing. ED to have the following submitted by 1/6/2025:

1. LIC500 Personnel Report
2. Staff schedules for all shifts in the assisted living unit.
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Based on interviews and record review the licensee did not comply with the section above for not having sufficient staff to meet residents' needs such as assistance with 2 person transfers, diapering needs during NOC shift, which posed potential health and personal rights risks to persons in care.
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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: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/11/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240811203347

FACILITY NAME:LAKE PARK SENIOR LIVINGFACILITY NUMBER:
019201182
ADMINISTRATOR:MEDINI, ROZAFACILITY TYPE:
741
ADDRESS:1850 ALICE STREETTELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 97DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kirsten Korfhage, Executive DirectorTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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The facility has not performed required annual re-appraisals

Facility does not have a required Dietician
INVESTIGATION FINDINGS:
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On 12/04/2024 at 2:00PM, Licensing Program Analysts (LPAs) Carol Fowler and arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with Executive Director, Kirsten Korfhage and explained to her the reason for the visit.

During the course of the investigation, the Department conducted interviews with residents, staff, and witnesses. The Department obtained and reviewed the facility & staff roster, staff schedule and staff training's. LPAs also reviewed a sample of residents re-appraisal and Physicians Reports.

Allegation: The facility has not performed required annual re-appraisals.
Investigation Finding: unsubstantiated
It was reported to the Department that the facility has not performed required annual re-appraisals.

Continue on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240811203347
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: 12/04/2024
NARRATIVE
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Continue from LIC 9099 A

The Department reviewed samples of resident’s files (7 out of 21 sampled), conducted interviews with staff and residents which revealed 1 resident out of the 7 with an expired re-appraisal. Therefore, this allegation is unsubstantiated.

Allegation: Facility does not have a required Dietician
Investigation Finding: unsubstantiated

It was reported to the Department that the facility does not have a dietician as required for RCFE’s with a capacity of 50 or more residents. The Department conducted interviews and reviewed documents which revealed that the facility has a dietician on staff that signs off all menus and is available to residents if requested. Therefore, this allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations that the facility has not performed required annual re-appraisals and facility does not have a required dietician.

Exit interview conducted. A copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5