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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:57:33 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
03/07/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250307141755
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: 102DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Fouzia Yaagoub, Business Office ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not ensure the facility elevator is properly operating
INVESTIGATION FINDINGS:
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On 03/11/2025 at 9:45 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to conduct a 10 day initial complaint investigation for the allegation above. Upon arrival, LPA met with Fouzia Yaagoub, Business Office Manager, and explained the reason for the visit.

During the course of the investigation, LPA conducted an interview with Fouzia, interviewed the head of maintainance, and spoke with/observed the elevator repair technition from Metro repairing elevator. LPA also interviewed residents.

Allegation: Facility elevator is in disrepair.
Investigation Finding: Un-Substantiated

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

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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-20250307141755
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: 03/11/2025
NARRATIVE
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Continued from LIC9099

LPA interviewed two (2) residents (R1, R2) regarding the allegation. Both residents spoke about how elevator 1 had been closing on residents. Although the elevator was closing on residents, no injuries were reported by either resident.

LPA also interviewed one (1) Staff (S1) in this matter. S1 reported to LPA that Metro Elevator is Lake Park's elevator repair company. S1 had placed a service call to Metro Elevator the day before due to concerns brought by residents. The Metro Elevator technician was on site repairing the elevator at time of interview with S1. LPA was able to observe the repair technician repair the sensor in the elevator and rode the elevator a few times to ensure it was functioning correctly.

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 the facility’s elevator is in disrepair 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: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2