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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 12/10/2024
Date Signed: 12/10/2024 04:37:22 PM

Substantiated


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
07/01/2024 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20240701153826
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: 98DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director, Kirsten KorfhageTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Facility not complying with approved plan of operation
INVESTIGATION FINDINGS:
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On 12/10/2024 at 2:45 PM, Licensing Program Analyst (LPA), D. Doidge accompained by Licensing Program Manager (LPM) J. Fong, conducted an unannounced continuing complaint visit, meeting with Executive Director, Kirsten Korfhage, and explained the nature of the visit.

Allegation: Facility not complying with approved plan of operation

Finding: Substantiated

At complaint filing, the Department was informed that the electronic admission agreement that Lake Park is utilizing was incorrect and had conflicting terms and language; whereby language pertaining to independent individuals aged 55 and older was comingled with language pertaining to licensed RCFE residents.

Continued on LIC 9099-C
Substantiated
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 4
Control Number 15-AS-20240701153826
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: 12/10/2024
NARRATIVE
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Continued from LIC9099

Per previous complaint filed on 4/2/24, Control Number 15-AS-20240402175048, with the allegation that the facility changed the plan of operation without CCLD approval, a copy of an admission agreement was obtained which did show that there was language pertaining to independent, general renters, aged 55 and older that was mixed with licensed RCFE language.

Therefore, the allegation was previously investigated and substantiated on 7/25/24.

The allegation for this complaint, Control Number 15-AS-20240701153826, is Substantiated, however no deficiencies are being issued on today’s date due to the previous Substantiation and Deficiencies cited on 7/25/24.

Exit Interview conducted, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/01/2024 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20240701153826

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: 98DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director, Kirsten KorfhageTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/2024 at 2:45 PM, Licensing Program Analyst (LPA), D. Doidge accompained by Licensing Program Manager (LPM) J. Fong, conducted an unannounced continuing complaint visit, meeting with Executive Director, Kirsten Korfhage, and explained the nature of the visit.

During the course of the investigation, the Department conducted interviews with W1, W2, W3, W4, W5, and W6, which included current and former staff. The Department obtained and reviewed the facility & staff roster.

It was reported to the Department that the facility staff mismanaged resident’s medication. The department conducted interviews and reviewed R1’s MAR, medication count sheet, physician report, care plan, and medication staff communication log which revealed that R1 was provided PRN medication as (needed) prescribed, and that the documentation for the subject medication as stated by W1 were all in order. W2, W3, W4, and W5 either had no knowledge of a medication error. Per W1, the subject medication was removed from the facility by family and that 4 more pills were present than what should have been in the bottle. However, because the medication had been removed the facility, it is not possible to determine what the number of pills were present before being taken out of the facility. Therefore, this allegation is Un-Substantiated.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20240701153826
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: 12/10/2024
NARRATIVE
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Continued from LIC9099

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 allegation Staff mismanaged resident's medication is un-substantiated.


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

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4