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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 04/22/2025
Date Signed: 04/22/2025 03:26:21 PM

Substantiated


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
03/25/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250325154908
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:
03:50 PM
ALLEGATION(S):
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Licensee is not ensuring that facility elevator is maintained in good repair.
INVESTIGATION FINDINGS:
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On 04/22/2025 at 11:10 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Fouzia Yaagoub, Business Office Manager.

Allegation: Licensee is not ensuring that facility elevator is maintained in good repair.

Findings: LPA had previously spoken to staff regarding the elevator. Based on observation and interviews with staff and residents, elevator two has been out of service since November. Despite efforts made by management to get the elevator repaired, it remains nonoperational, therefore the allegation above is SUBSTANTIATED.

Continued on LIC9099-C
Substantiated
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 3
Control Number 15-AS-20250325154908
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be ...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Executive Director now has a clear date of May 5th to have the elevator repaired. Deficiency cleared during visit.
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Based on observation and records, Elevator two has been inopeerational since November.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250325154908
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 form LIC-9099

The preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 809-D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result civil penalty.

Deficiency plan and proof of correction were discussed with BOM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and 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: 3 of 3