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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 04/22/2025
Date Signed: 07/01/2025 10:07:44 AM

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
04/18/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250418133940
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: 100DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Fouzia Yaagoub, Business Office ManagerTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility does not have sufficient staff to meet residents needs in the provision of food services.
INVESTIGATION FINDINGS:
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On 04/22/2025 at 11:10 AM, Licensing Program Analyst (LPA) D. Doidge unannounced to conduct a 10 day initial complaint investigation for the allegation above. Upon arrival, LPA met with Fouzia Yaagoub, Business Office Manager to open a complaint.

During the course of the investigation, LPA conducted interviews with multiple staff, and residents. LPA also obtained, reviewed, and received copies of the LIC500, food service staff shift schedule, Physician's Reports (602) and Apprasial Needs and Services (ANS) for a sample of residents. .

Allegation: Facility does not have sufficient staff to meet residents needs in the provision of food services.

Findings: LPA observed that there is sufficient staff for food service, and that no resident requires assistance with feeding.

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

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
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-20250418133940
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: 04/22/2025
NARRATIVE
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Continued from LIC9099

Record review, and staff interviews confirmed no resident requires assistance with feeding, nor does any resident have a doctor ordered meal time. Therefore the above allegation is Un-Substantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations above do not meet Regulation Requirements are 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: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2