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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 01:43:26 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
01/17/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250117120802
FACILITY NAME:LAKE PARK SENIOR LIVINGFACILITY NUMBER:
019201182
ADMINISTRATOR:KORFHAGE, KIRSTENFACILITY TYPE:
741
ADDRESS:1850 ALICE STREETTELEPHONE:
(510) 835-5511
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY:275CENSUS: 99DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Executive Director, Kirsten KorfhageTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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The facility’s Disaster Plan does not meet Regulation Requirements
INVESTIGATION FINDINGS:
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On 01/23/2025 at 1:28 PM, Licensing Program Analysts (LPAs) D. Doidge and C. Fowler, arrived unannounced to conduct a 10 day initial complaint investigation 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, LPAs conducted an interview with staff, reviewed and received a copy of the staff roster, and the Disaster Plan.

Allegation: The facility’s Disaster Plan does not meet Regulation Requirements.
Investigation Finding: Un-Substantiated

It was reported to the Department that the facility’s Disaster Plan is out of compliance. The RO received further information that the Evacuation component of the Disaster Plan has an expired date. Upon interview and review of the Disaster Plan, LPAs observed the plan to be current.

Continued on LIC9099
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-20250117120802
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 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 facility’s Disaster Plan does not meet Regulation Requirements is un-substantiated.

Exit interview conducted and a copy of this report provided.
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