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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 04/22/2025
Date Signed: 06/27/2025 03:29:58 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
04/17/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250417130751
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 Manager TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility does not employ a qualified food service consultant

Disaster drills are not being conducted as required
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 staff, and received and reviewed the Disaster Drill Log.

Allegation: Facility does not employ a qualified food service consultant.

Findings: Based on interviews with staff, LPA confirmed the facility does have a full-time employee qualified by formal training for food planning, preparation and service, as well as a dietician to consult in meal preparations. Therefore this allegation is UNSUBSTANTIATED.

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-20250417130751
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 LIC-9099

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 above does not meet Regulation Requirements and is unsubstantiated.

Allegation: Disaster drills are not being conducted as required.

Findings: Based on record review, and staff interviews, LPA confirmed disaster drills are held monthly and logged appropriately. Therefore this allegation is UNSUBSTANTIATED.

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 above does not meet Regulation Requirements and is unsubstantiated.

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