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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 01/23/2025
Date Signed: 01/23/2025 01:25:08 PM

Unsubstantiated


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
02/16/2024 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20240216172359
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: DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive Director, Kirsten KorfhageTIME COMPLETED:
01:27 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
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On 01/23/2025 at 11:57 AM, Licensing Program Analysts (LPAs) D. Doidge and C. Fowler arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPAs met with Executive Director, Kirsten Korfhage, and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with a witness, current and former, staff. The Department obtained and reviewed the facility & staff roster, MAR, Medication Count Sheet, Physician’s Report and Medication Staff Communication Log.

Allegation: Staff mismanaged resident's medication.
Investigation Finding: Un-Substantiated

Continued on 90999-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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 2
Control Number 15-AS-20240216172359
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: 01/23/2025
NARRATIVE
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Continued from 9099

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. Medication was removed from the facility before LPA could verify count.

Therefore, this allegation is Un-Substantiated.

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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2