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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201182
Report Date: 06/19/2025
Date Signed: 07/01/2025 10:07:16 AM

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
06/17/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250617153955
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: 121DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Executive Director, Kirsten KorfhageTIME COMPLETED:
05:00 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 06/19/2025 at 11:15 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to conduct an initial 10-day complaint investigation, and deliver findings for the allegation above. Upon arrival, LPA met with Executive Director, Kirsten Korfhage, and explained the purpose of the vest.

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

Findings: LPA had previously interviewed staff and residents regarding the elevator. Based on observation and interviews, 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: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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-20250617153955
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: 06/19/2025
NARRATIVE
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Continued form LIC-9099

Based on interviews and observation, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on LIC9099-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.



*An immediate Civil Penalty of $250 is being assessed on today's date for a repeat violation*

Deficiency plan and proof of correction were discussed with ED..

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: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250617153955
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: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2025
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 agreed to by July third to update LPA with an updated date as to what the issues witht eh elevator to get a clear repair date.
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This requirement was not met as evidence by:
Based on observation the Licensee did not comply with the section cited above in having elevator in disrepair, which posed an immediate health and safety risk to persons in care.
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*An immediate Civil Penalty of $250 is being assessed on today's date for a repeat violation*
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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: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3