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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201182
Report Date: 12/04/2024
Date Signed: 12/04/2024 04:40:32 PM

Document Has Been Signed on 12/04/2024 04:40 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
OAKLAND ASC, 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: 97DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Executive Director, Kirsten KorfhageTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 12/04/2024 at 02:00 PM, Licensing Program Analysts (LPAs) D. Doidge and C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with, Executive Director, Kirsten Korfhage and explained the purpose of the visit.

LPAs toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 112.2 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/12/2024. Emergency disaster drill was last conducted on 11/26/2024. First aid kit was observed to be complete.

LPAs reviewed five (5) resident records and five (5) staff records, all were complete.

No deficiencies observed or cited during this visit. .

Exit interview conducted and a copy of this report provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
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.

LIC809 (FAS) - (06/04)
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