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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 01/09/2025
Date Signed: 01/09/2025 05:25:11 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
04/26/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240426144046
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: 99DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kirsten Korfhage, Executive DirectorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Staff did not provide resident’s authorized representative with records

Staff did not provide resident with privacy
INVESTIGATION FINDINGS:
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On 1/9/2025 at 1:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Kirsten Korfhage, Executive Director and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witnesses, resident, obtained and reviewed records.

Staff did not provide resident’s authorized representative with records.
Based on interview with W1 the facility did not provide R1’s responsible party with requested documentation in R1’s file in a timely manner. W2 stated the documentation was first requested late 2023 to early 2024. LPA reviewed an email

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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
Control Number 15-AS-20240426144046
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: 01/09/2025
NARRATIVE
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Continued from LIC9099.

dated August 9, 2023, that requested documentation from the facility for R1. There was another email on April 23, 2024, that involved the Ombudsman regarding documentation for R1’s responsible party, lastly LPA reviewed an email dated April 25, 2024, that indicated R1’s responsible party received documentation.

Staff did not provide resident with privacy.

Based on initial interview W1 stated the staff are disturbing and not providing the resident with privacy by constantly coming into the resident’s room. W2 stated during interview staff would barge in R1's room without knocking. Review of charting records from October 2023 to April 2024 indicated how many times staff come in R1’s room per day and what was done or said. LPA observed that on some days staff charted 10 different times staff would go to R1’s room. S6, S7, and S8 stated during interview that staff was instructed by S4 to go to R1’s room to do checks. S7 and S6 stated this is not done to all residents. Same staff stated R1 does not get as many checks now just a few reminders.

Based on LPA observations, interviews which were conducted, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations 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. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
04/26/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240426144046

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: 99DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kirsten Korfhage, Executive DirectorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Staff falsified appraisal documentation to increase rent

Staff did not provide a comfortable environment for resident

Staff did not assist resident with hygiene needs

Staff did not assist resident with laundry
INVESTIGATION FINDINGS:
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On 1/9/2025 at 1:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Kirsten Korfhage, Executive Director and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witnesses, resident, obtained and reviewed records.

Staff falsified appraisal documentation to increase rent.

W1 stated during initial interview that documentation was falsified to show staff was doing more for R1 to increase the rent. Based on interviews with S6, S7, and S8 they were given instruction to document, but the documentation was not false. S8 was the

Continued on LIC9099C.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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 6
Control Number 15-AS-20240426144046
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: 01/09/2025
NARRATIVE
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Continued from LIC9099.

only staff person that was aware of this type of charting being done to another resident. W2 stated there were two (2) ex-employees told by S4 to get the level of care points up, which would increase the monthly service fee.

Staff did not provide a comfortable environment for resident.

Based on interview with W2 the facility was not welcoming and was a hostile environment. W2 recalled R1 being put in an elevator to go to the lobby and got lost in the basement. W2 felt this action was done intentionally. Based on review of preplacement appraisal dated 5/27/2023, R1 would not need any assistance moving around facility once fully acclimated to the new environment. LPAs spoke with two (2) residents during visit. Both R1 and R2 did not have any complaints about the facility or staff. LPAs observed both rooms were clean, and residents had their possessions.

Staff did not assist resident with hygiene needs.

During interview with witnesses both stated R1 did not want assistance with hygiene. W1 stated this allegation should not have been made and maybe there was a misunderstanding when reporting. W2 stated that R1 needed a reminder or help possibly once a day with toileting.

Staff did not assist resident with laundry.

During interview with witnesses both stated R1 did not want assistance with laundry. W1 stated this allegation should not have been made and maybe there was a misunderstanding when reporting. W2 stated the responsible party takes care of R1’s laundry.

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20240426144046
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: 01/09/2025
NARRATIVE
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Continued from LIC9099C.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20240426144046
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: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
87468.2(a)(19)
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(a) In addition to the rights listed in Section 87468.1... the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days...
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Executive Director agreed to have an in-service training on personal rights for all employees and submit sign-in sheet to CCLD by POC date.
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This requirement was not met as evidence. Based on observation and interview the Licensee did not comply with the section cited above in providing prompt access to resident's responsible party, which poses a potential health and safety risk to persons in care.
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Type B
01/24/2025
Section Cited
CCR
87468.2(a)(1)
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(a) In addition to the rights listed in Section 87468.1... (1) To have a reasonable level of personal privacy in accommodations... personal care... This requirement was not met as evidence by:
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Executive Director agreed to have an in-service training on personal rights for all employees and submit sign-in sheet to CCLD by POC date.
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Based on interviews and record review the Licensee did not comply with the section cited above in giving resident peronal privacy which poses a potential health and safety risk to person 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6