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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 12/12/2024
Date Signed: 12/12/2024 01:14:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
02/20/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240220153014
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: 94DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kirsten Korfhage, Executive DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility is in financial distress.
INVESTIGATION FINDINGS:
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On 12/12/2024 at 10:45 AM, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge conducted a subsequent visit and met with Executive Director, Kirsten Korfhage to deliver findings of above allegation. LPA explained the purpose of the visit with Executive Director.

During the investigation, the LPA obtained the following documents from the facility – copies of utility billing statements.

Allegation: Facility is in financial distress.
Finding: Substantiated

During the investigation, the LPA conducted interviews of facility staff (S), residents (R) and witnesses (W). On 02/21/2024 and 03/13/2024 LPA obtained copies of utility bills and past due notices for PG&E and Waste Management and observed that the accounts were in arrears.

LIC9099-C Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
02/20/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240220153014

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: 94DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kirsten Korfhage, Executive DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility plumbing is in disrepair.
INVESTIGATION FINDINGS:
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On 12/12/2024 at 10:45 AM, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge conducted a subsequent visit and met with Executive Director, Kirsten Korfhage to deliver findings of above allegation. LPA explained the purpose of the visit with Executive Director.

Allegation: Facility plumbing is in disrepair.
Finding: Unsubstantiated

On 02/21/2024 LPA interviewed S1. S1 that stated the facility was having plumbing issues.

On 02/21/2024 LPA interviewed R1. R1 stated that there was an issue the day before with the water on 02/20/2024.

LIC9099-C
Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20240220153014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
VISIT DATE: 12/12/2024
NARRATIVE
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LIC9099-C (Page 2)

On 12/11/2024 LPA interviewed S4. S4 stated that per the Maintenance Director (MD) has confirmed that there was some plumbing work upgrades that were completed in the community regarding the ball valves in 2023. The work was planned with notices be distributed to all of the residents notifying them of the water shut for a period of time on the particular day. The MD explained that they did the A wing one day, drained all of the water, completed the work and turned the water back on. The next day same notices went out to the residents in the B wing and worked commenced the same as the day before. The MD said the work went smoothly with no complaints.

S4 further stated that this work was preemptive so that if there was a need to shut off water during an emergency leak, the ball valves would be easier to close. The building had plug valves that were identified as old and needing replacement.

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.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20240220153014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
VISIT DATE: 12/12/2024
NARRATIVE
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LIC9099-C (Page 2)

On 02/21/2024 LPA interviewed S2. S2 stated that the facility had received 7-Day Notices from Pacific Gas & Electric Company (PG&E) and past due notices and Final Demand Notices from Waste Management.

On 02/23/2024 LPA interviewed W1. W1 stated that they were contacted by Lake Park Senior Living in August 2023 for a sewer lateral repair. W1 stated that they presented a proposal for the project and was hired by Lake Park Senior Living to complete a two (2) phase project. W1 stated that they completed the first phase of replacing five (5) laterals which was invoiced for $42,800.00. W1 stated that the second phase proposal would be “pretty involved” and that they gave an estimated total of $179,410.00. W1 stated that they did not receive payment of $42,800 for the first phase and there was no further communication from management whether to proceed with the proposed second phase of the project. On 02/27/2024 LPA interviewed S1. S1 stated that another contract plumber was hired to replace twenty-seven (27) ball valves. S1 stated that the contractor invoiced on 09/22/2023 for $8,514.99 and that payments have not been paid.

On 04/09/2024 LPA interviewed S1. S1 stated that two (2) of the residents (R1 and R2) had one-on-one care attendants in which were arranged by previous administration. S1 stated that the parent company, Pacifica, said that they did not approve the service and were not going to pay for caregiving services. S1 stated that they received a collection notice for non-payment from one of the resident’s caregiver agencies. S1 stated that the pest service, satellite television service was also disconnected for non-payments.




LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20240220153014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
VISIT DATE: 12/12/2024
NARRATIVE
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LIC9099-C (Page 3)

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20240220153014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LAKE PARK SENIOR LIVING
FACILITY NUMBER: 019201182
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
87213
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The licensee shall have a financial plan that … assures sufficient resources to meet operating costs for care of residents…”



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Administrator agreed to provide evidence that payments for PG&E, WM, pest service, plumber and caregiver services are paid and accounts are current and wil submit proof to CCLD by POC due date.
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Based on investigation, licensee did not comply with the section cited above by receiving several past due notices for PG&E (dates 11/29/23 thru 01/30/24), Waste Management (dates 02/14/23 thru 01/10/24; and per W1, contractor has not been paid for work performed.
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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: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6