Lakeside Park

On 2/17/2022 starting at 1:10 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Julie Peterson. Upon entry, LPA’s temperature was checked and asked Covid-19 symptoms questions by the staff . LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen and common areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.

Continued from LIC9099 LPA and LPM reviewed the medication list and eMAR for R1, R2, R3 and R4 with S1. eMAR showed that over the course of three months no medication doses were missed. S1 informed LPA and LPM of medication distribution procedures including steps taken if dosages are not given or are missing. While reviewing eMAR with S1, LPA David Doidge observed R2 had an extra box of medication opened before the previous box had been used. S1 informed LPA and LPM that the initial box had been misplaced and a new box was opened to prevent a mis-dose. S1 informed LPA and LPM that the facility had two boxes available, which was observed by LPA David Doidge. The initial box had fallen out of R2’s medication box while all medication were being transferred to a new medication cart the facility is now using. A few days later the initial box was found behind R2’s medication box and the med techs started using both boxes until S1 counted the contents of box two, made a note, then taped box two closed informing the other med techs to only use box one until remaining doses were used before using the second box. LPA David Doidge counted the contents of both boxes, reviewed eMAR and noted no missing doses. Therefore the 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 that staff did not administer medication to a resident in care is unsubstantiated. No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.

Continued from LIC9099 Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report was provided.

Continued from LIC9099 Allegation: Staff threatened resident in care Investigation Finding: LPA spoke with S1 and S2 and confirmed that the facility has the right to charge residents for use of space that is not part of the original agreed upon rental space.This is also confirmed in the Admission Agreement. Therefore this allegation is unsubstantiated. Allegation: Staff did not properly follow resident's medical orders Investigation Finding: LPA interviewed S1 and S2 who both confirmed that residents have a daily walking activity, weather permitting, and other activities that take residents outside. LPA reviewed the activities calendar confirming multiple outdoor activities are available. R1's 602 does not specify that R1 needs to be taken outside or for daily walks. This allegation is therefore unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted and a copy of this report was provided.

Continued form LIC9099 Allegation: Staff do not administer residents medication in a timely manner Finding: LPA observed in both interview and record review that although staff may administer medication at different times day-to-day, residents are still receiving medication in a reasonable time frame during each Med Tech shift. There is adequate overlap in the Med Tech schedules to ensure no resident goes with out medication and that all medications are delivered in a timely manner for each shift. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted and a copy of this report was provided.

The Department interviewed W1. W1 stated R1 was in the facility for approximately 5 months. W1 stated that R1 had “full on Alzheimer’s.” W1 further stated that she was aware that on 6/17/24, R1 was admitted to the hospital. W1 was unsure on the reason of the hospital visit. W1 stated R1 had cancer, but the “cancer wasn’t killing him, it just weakened him.” W1 also stated that after the hospital visit, R1 was placed on hospice and then died about two days later. W1 claimed that the facility staff weren’t keeping R1 hydrated by allowing him to drink only soda and that they left him in dirty diapers causing R1 to get a UTI and sepsis. The Department interviewed S1. S1 stated that R1 had a steady decline in health while at the facility with multiple falls regardless of staff intervention and alarms that were put in place. R1 liked to be independent and would get out of bed on his own. S1 also stated that there was a problem with keeping R1 hydrated as he preferred to only drink Coca Cola however the facility offered water and juices to R1 as well. Interviews with the other facility staff (S2, S3, S4 and S5) all revealed the same information; that R1 was in a steady decline of health during his time at the facility, that R1 refused to drink water or juice preferring Coca Cola. Per staff, R1 sustained several falls even with staff intervention and bed alarms that were put in place. R1 had multiple falls due to R1 thinking R1 was independent and capable of transferring himself out of bed in order to get to the bathroom. R1 did sustain multiple urinary tract infections (UTI) R1 did wear diapers but was always cleaned in a timely manner. No staff reported that R1 ever had an issue with being dirty or sitting in a dirty diaper for prolonged periods of time. Staff were all trained to change residents as soon as they observed that the diaper was soiled. On 6/16/24, R1 sustained an unwitnessed fall. R1 was evaluated by S5. S5 assessed the resident with no injuries, R1 had no complaints of pain, and vitals were normal. R1 remained at the facility and S5 monitored him for any change to baseline. R1 was sent to the hospital for an evaluation after S3 noticed R1 was not acting like himself. At the hospital R1 was diagnosed with “Sepsis without acute organ dysfunction, due to unspecified organism.” ***report continues on LIC9099C*** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ***report continues from LIC9099C*** Review of R1’s Certificate of Death from the County of Alameda states that R1 died on 6/25/24. Immediate cause of death was listed as to Sepsis, Metastatic Prostate Cancer, and Dementia. Secondary Cause of death was listed as, Diabetes Mellitus Hypertension. The Department has investigated the complaint alleging questionable death and staff did not properly change resident resulting in resident developing a UTI and Sepsis while in care. The Department has found that the allegations above are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

Allegations: Facility staff do not ensure resident rooms are kept clean, Facility staff did not properly maintain a resident's room, and Staff do not properly maintain the resident’s room: Unsubstantiated LPA tour the facility and randomly sample 10 residents room including and not limited to Piedmont Manor and Merritt House. LPA observed that 10 out of 10 residents’ room properly maintain. LPA observed residents’ beds are made, and no smell of odor. LPA reviewed housekeeping and laundry log for the month of April till present and it indicated that housekeeping is keeping track of the room/ floor that they are responsible. There are rooms that housekeeper must clean daily including and not limited to room 102, 104, 114, 117, 121, 125B, 209A, and 222. Allegation: Facility staff are not ensuring a resident's grooming needs are met: Unsubstantiated LPA conducted interview with R1, R2, and R3 regarding their grooming needs are being met by the facility staff. 3 out of 3 stated that the facility staff are great and does meet their grooming needs. R2 stated when R2 needs any assistance with bathing staff would assist R2. R1 stated “something I don’t need any assistance with grooming, so I refused their assistance”. R3 stated “my needs are being meet, and I have no complaint about any assistance not meeting my expectations”. Allegation: Facility staff do not ensure that residents are fed: Unsubstantiated LPA interviewed R1, R2, and R3 regrading the above allegation of facility staff do not ensure that residents are fed. 3 out of 3 stated “I get fed three time a day, but something I don’t want to eat so I refused it”. R3 stated “when I refused my meal, staff comes around after and check in with me to encourage me to eat”. LPA reviewed residents care note shows that staff are following their round checking in with residents if they refused their meal”. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted and a copy of this report was provided.

continue from LIC 9099 Allegation: Staff do not keep the facility free from mold Investigation Finding: unsubstantiated. LPA toured the facility including the kitchen area walk in refrigerator and freezer and there were no signs of mold. Interviews with S1, S2 and S3 there has not been a mold issue that staff is aware of. Allegation: Staff do not properly maintain the facility's drainage system Investigation Finding: unsubstantiated. Interview with S1 and S2 revealed that there has not been a drainage issue at the facility. S2 stated there has been normal toilet backups due to residents over use of toilet paper and flushing paper towel, diapers and other non-flush able items. Allegation: Staff do not provide adequate laundry service for the residents Investigation Finding: unsubstantiated. Interview with S2, S3 and S4 revealed that residents laundry is serviced daily. S4 stated that laundry for each resident is conducted the same day as their shower schedule, however, if a residents laundry is full staff will wash their laundry. S2 and S3 stated that if there is an issue with the washer and dryer on the 1st or 2nd floor the large laundry room will wash or dry the residents laundry. S3 stated that the large laundry room is for washing residents linen, which is washed daily and also stated that if there is an issue with one of the washers or dryers on the 1st and 2nd floor the residents laundry will be serviced in the large laundry room. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Allegation: Staff do not ensure the residents consume an appropriate amount of liquid: Unsubstantiated LPA reviewed care notes that staff are encouraging R1 to drink more liquid. LPA interview S1 stated that R1 doesn’t like to drink the amount of liquid that are given to R1. S1 indicated that even when staff encouraged R1, R1 tend to ignore and said “yea…yea…I know”. LPA interview R1, R1 stated that R1 doesn’t like to drink a lot of liquid. Staff goes around and offered beverages, but R1 doesn’t want to take the offered. R1 stated R1 doesn’t like to drink a lot of liquid (repeated twice). Allegation: Staff do not prevent the residents from sustaining injuries while in care: Unsubstantiated LPA interviewed S1, R1, R2, and R3. S1 stated that staff do there ensured checked with residents every four hours. Staff walked around to monitor residents. Residents that stay in their room have their door open or half open, so staff do their walk through. R1 stated that staff checked on me often, because R1 stated that R1 likes to stay in R1 room. R1 stated that “I am an old man so it’s normal that I fall. I don’t like to ask for help because I like to be independent”. S1 noticed that R1 likes to be in R1 socks and doesn’t like to put on slipper. R1 likes to do things independently, and when R1 wear socks the floor can be slippery R1 can fall, so staff pays more attention to R1 to prevent R1 from falling. S1 stated same goes with other residents if they refused then staff can’t force them, but to keep on encouraging. Staff encouraged R1 to wear slipper, but R1 refused, S1 stated most of the residents doesn’t like to be help they like to do thing themselves. Report Continue on LIC 9099c... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff allow the residents to be soiled for an extended period of time: Unsubstantiated LPA interviewed S1, R1, R2, and R3 regarding the duration of times that staff allow the residents to be soiled for an extended period of time. S1 stated that residents don’t want to be change at time, and staff have to just encouraged residents. R1 stated R1 doesn’t like to ask for assistance, and staff comes and provide the assistance, but R1 refused at time. R2, and R3 stated they don’t wait for a long time for staff to come and change them whenever they have an accident. Allegation: Staff do not properly maintain the resident’s room: Unsubstantiated LPA tour the facility and randomly sample 10 residents room including and not limited to Piedmont Manor and Merritt House. LPA observed that 10 out of 10 residents’ room properly maintain. LPA observed residents’ beds are made, and no smell of odor. LPA reviewed housekeeping and laundry log for the month of April till present and it indicated that housekeeping are keeping track of the room/ floor that they are responsible. There are rooms that housekeeper must clean daily including and not limited to room 101, 102, 103, 104, 105, 118, 122, and 124. Report Continue on LIC 9099c... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff do not provide the residents assistance to the restroom. Unsubstantiated LPA interviewed R1, R2, and R3 regrading if staff assist with restroom. 3 out of 3 stated that staff do assist them with the restroom when they needed. R1 stated most time R1 doesn’t like to ask for assistance and doesn’t want assistance from staff because R1 stated that R1 can use the restroom without any assistance. S1 stated that when residents refused, they cannot force them. Care staff are to do their round and go a check back with those residents that refused and offered their assistance to the residents. RP stated “at time residents refused staff assistance and want to use the restroom themselves””. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted and a copy of this report was provided.

Continued from LIC9099 Investigation Finding: unsubstantiated. During the investigation LPA interviewed W1 and S1. W1 reported concerns regarding R1’s multiple falls and stated the facility did not notify W1 on one occasion When R1 had a serious fall and was transferred to the hospital or returned to the facility. W 1 also stated that staff were not attentive to R1 and that R1 was often observed ambulating unsupervised throughout the facility, despite the facility being aware that our one was a fall risk. Find the interview with S1 stated that R1 was permitted to ambulate freely within the designated areas of the facility and that there were no physician orders indicating that R1 was non ambulatory. S1 further stated that the facility notified R ones responsible party each time R1 experienced a fall and that the physician was informed after each incident. The LPA conducted record review our facility records including progress notes physician communication forms which confirm that the responsible party and physician were notified following each fall based on interviews and record review the allegation is unsubstantiated. Allegation: Staff did not prevent outbreak of scabies. Investigation Finding: unsubstantiated. Continued on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC90999 During the investigation LPA interviewed W1 and S1. W1 stated that during a visit with R1, a resident approached and began petting W 1's dog. W one reported that a staff member (name unknown) informed W one that the resident had scabies and that the resident had wandered from a quarantine area. S1 stated that the facility experienced A scabies outbreak and that all symptomatic residents were quarantined in their rooms on the 2nd floor. Staff assigned to the second floor worked exclusively with quarantine residents. Residents who were not quarantined were allowed to ambulate throughout the facility except for the second floor. S1 further stated that a physician evaluated the situation and prescribed preventative medication to residents. The facility was unable to determine which resident initially introduced scabies into the facility. S1 confirmed that the facility followed its outbreak control policy. Based on interviews and record review this allegation is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management visit in connection with a Priority 1 complaint #15-AS-20231020144049 and met with Program Director Ieshiaa Ragland. LPA explained to Ieshiaa the purpose of the visit. The facility is a three storey building. All the offices are located on the street level area. Residents are located on the next two levels. The facility serves clients with Dementia. There were 23 residents on the 1st level and 20 residents on the 2nd level. Residents were observed engaged in different activities. Residents appeared to be neat and well groomed. Facility was clean and odor free. LPA with Program Director and Maintenance Director checked hot water in Merritt, Berkeley and Piedmont areas and observed at temperature was at 127.4 degrees Fahrenheit. Type A deficiency is cited per Title 22 California Code of Regulations (see Lic 809D). Exit interview was conducted with Ieshiaa and Appeal Rights was provided.

On 01/17/2025 at 10:00 AM, Licensing Program Analysts (LPA) D. Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Resident Care Director Jocelyn Fabros and explained the purpose of the visit. LPA toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 114.6 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 10/04/2024. Emergency disaster drill are conducted monthly, last conducted on 12/18/2024. LPA reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report provided

Visiting documents and progress notes indicated that home health was visiting R1 for wound care on R1's legs. Home health would assist R1 in changing the dressings on R1's legs. R1 was admitted to hospice care on 9/20/2024 and hospice assisted in wound care for R1 after that date. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

On 7/25/24 at 3:00 PM, Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Grant Haywood, Administrator and explained the purpose of the visit. LPA toured facility including but not limited to the apartments, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 118 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in the med room. Smoke detectors and carbon monoxide detector were observed to be operational. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 9/1/23. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

LIC9099-C Continued... LPA interviewed R1 who was observed sitting in the common area amongst other residents watching television. S1 brought R1 over to a quiet area so that LPA Alexander could talk and ask R1 some questions. LPA observed that R1 was in a good mood, sharing some memories of family, military background, hometown and profession as a former educator and jazz musician. R1 stated that they are treated ok at the facility, and do not have any issues or concerns. Allegation: Night staff sleeping during work hours Unsubstantiated. On 07/10/2024 LPA interviewed Staff (S) S1- S4. It was alleged that night staff is sleeping during work hours. S1 stated that the Night Shift (NOC) schedule is from 10pm to 6:15am and that they try to schedule two (2) Nayas "...person with wisdom and guidance..." (caregiver) to each floor and one (1) Med-Tech which end their shift at 6:30am. S1 stated that they have no knowledge of any NOC staff that is sleeping and not being attentive to the residents. S1 stated that Naya's are doing their rounds, checking on residents every hour, helping with the inventory and staying busy. S1 stated that they have had in-training regarding being alert, watching 1-2 of the residents that are wanderers, and staying woke and not sleeping while being on work duty. S2 stated that they work during the day shift and generally they pass out medications. S2 stated that sometimes they will assist a resident to the bathroom if one of the Nayas is busy with another resident at that time. S2 stated that they have no knowledge of any of the staff sleeping during the NOC. LIC9099-C (Page 2) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C Continued... S3 stated that they have no knowledge of any staff at the facility sleeping and not being alert and awake during work hours. S4 stated that they have no knowledge of any staff sleeping during the NOC shift and that also includes the evening shift that they currently work. LPA L. Alexander asked S1 if any of the residents needed a two (2) person assist and S1 stated that there are a couple residents that need 2 person assist if they are in a wheelchair and need assistance. S1 stated that in this case another Naya would go and get another Naya to assist if needed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report was provided.

On 07/10/2024 at 3:00 PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit regarding an incident that was reported to CCLD on 07/02/2024 while conducting a complaint investigation, 15-AS-20240702150218 on 07/10/2024. LPA met with Executive Director, Grant Haywood, and explained the purpose of the visit. CCLD was notified that the facility did not have a current food director for the past 2 months. LPA reviewed current job posting for Dining Services Director, interim food director's resume and ServSafe Food credentials. S1 stated that the former food director was terminated about 2 months ago. However, S1 stated that another qualified food director is coming to their facility as an interim until they hire another food director. S2 stated that the food director, S3, is someone that use to work at the facility but currently is the food director at their sister facility, Watermark by The Bay located in Emeryville. S2 stated that they posted the position for Dining Services Director on 04/25/24 on Indeed; hiring job platform. S2 stated that they have conducted some interviews with possible candidates but have not found the right person for the position. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

On 05/22/2024 while at the facility for another reason, Licensing Program Analyst (LPA) A Gomez found that staff are not trained on how to utilize the emergency evacuation chair located in the stairwell. LPA spoke with S1 and S2 who stated that they have never been trained on utilizing the evacuation chair. S2 stated that they were not aware of what an evacuation chair was. LPA also spoke with the Executive Director who stated that they have not been trained on how to utilize the emergency evacuation chair at the facility. Staff where unable to demonstrate on how to properly utilize the chair. LPA informed the ED of the importance of knowing how to utilize the evacuation chair in the event of an emergency and ensuring that a chair is available at each stairwell. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

continuation from Lic 9099 R1’s preplacement appraisal indicates R1 is diabetic but does not need help with eating. Incident report submitted to CCL states that the Medication Technician (MT) observed R1 going to the bathroom, followed R1 to assist at around 5:05 pm on 10/15/2023. When the MT observed R1 looking pale, MT called a caregiver to assist. R1 passed out, staff then called 911 and performed CPR. The Department’s investigation concludes that there was no indication of lack of supervision. Staff were present and obtained immediate medical care. Autopsy was performed on R1 to determine the cause of death. R1’s death certificate recorded Asphyxia, choking on food bolus as the cause of death, manner of death as accident and time of death is 1705 hours. Autopsy was performed on R1 to determine the cause of death. Based on record reviews conducted, the above 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 or did not occur, therefore the allegation is unsubstantiated. There is no deficiency noted for this visit.

On 10/2/2024 at 12:30PM, Licensing Program Analysts (LPAs) G. Luk and D. Doidge arrived unannounced to conduct a case management visit. LPAs met with Executive Director, Grant Haywood and explained the purpose for the visit. While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20240926163458), the following deficiency was observed. After reviewing Guardian system, LPAs observed staff (S1) did not have criminal record exemption transfer to this facility. S1 left the facility during visit and will return once exemption transfer is approved. Civil penalty of $100 is being assessed. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.

On 02/28/24 at 10:15 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Sonia Taizan, Business office HR Manager and explained the purpose of the visit. LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. At 10:52 am LPA reviewed 6 residents records. At 11:45 am, LPA reviewed 5 staff records and 5 of 5 were fingerprint cleared and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Continued from LIC9099. stated R1 has experienced hallucinating episodes while at the facility. The Department also interviewed residents who did not have any concerns and felt safe at the facility. The Department reviewed Oakland Police Department’s report which indicated that on June 11, 2023, the police officers were dispatched to the facility and spoke with S1. The report also indicated the alleged incident occurred on June 9, 2023, which there was only one (1) male caregiver that worked that night. S1 also stated in the report that there are only two (2) male caregivers that worked at the facility. During the interview with S2 it was stated that S3 was assigned to R1 that night and on the NOC shift staff conducted checks on the residents every two hours. The staff try not to wake up the residents when conducting their routine checks, but that R1 regularly wakes up when he’s being assisted. S2 stated R1 had described the male staff and S3 was the only male staff working. Facility staff contacted the agency where S3 was employed and requested S3 to be removed from the rotation due to the allegation. The Department interviewed W1, the Director from the agency where the male staff was hired. W1 was aware of the incident that occurred at Lakeside and conducted an internal investigation at the agency. W1 stated that the male staff did give a statement stating he did assist R1 with toileting and had to assist by putting his hand on R1’s private part to place in urinal cup. Continued on LIC9099C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC9099C. Based upon the information obtained and the interviews during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is UNSUBSTANTIATED . Exit interview conducted. A copy of this report is provided.

On 6/19/2023 at 12:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint. LPA met with Lee Kaufmann, Managing Director and explained the reason for the visit. Upon arrival, LPA was greeted the receptionist. During the health and safety check LPA toured the facility with the Managing Director including but not limited to common areas, bedrooms and kitchen. LPA observed on the 2nd floor residents were having lunch and a couple of the residents were walking around. On the 1st floor LPA observed residents in common area. Facility is noted to be clean and in good repair and residents in care appear to be safe. There are no imminent health/safety concerns on today's date. No deficiencies were cited today. Exit interview conducted and a copy of this report provided.

Allegation: Resident was on the floor unattended LPA reviewed a risk management incident report dated 02/25/23 which showed resident (R1) had an unwitnessed fall on the side of the bed. S2 stated R1 had a bowel movement during the incident and did not complain of any pain at the time she was observed. S2 stated that staff along with R1's caregiver assisted R1 and was cleaned, diaper and beddings changed. S2 stated that residents are checked and monitored every 2 hours. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident was on the floor unattended did occur, therefore the allegation is unsubstantiated. Allegation: Resident's room was cold During visit, LPA observed resident's (R1) room temperature at 70 deg F per thermostat reading inside her bedroom. LPA also observed hallway temperature at 75 deg F per thermostat reading. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident's room was cold did occur, therefore the allegation is unsubstantiated. Allegation: Resident's room unkept LPA toured the 2nd floor with BD during visit. LPA observed residents' rooms (Rm 215 and 216) odor free with windows closed. LPA observed resident (R1) sitting comfortably in a chair next to the closed window. LPA observed R1 to be clean and well groomed. LPA did not see any soiled diaper or dirty clothing inside the bedroom. LPA observed R1' room to be clean and odor free with a few clean clothes sitting on a chair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident's room was unkept did occur, therefore the allegation is unsubstantiated. Exit interview conducted and a copy of this report provided.

On 2/8/2023 starting at 12:15 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Julie Peterson and explained the purpose of the visit. Upon entry, LPA’s temperature was checked and asked asked to complete the check-in process. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, and common areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.