Inspection Reports for Lake Park Senior Living

An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2025-07-08 regarding staff supplies, training, reporting, resident condition evaluation, pest control, food service, and facility maintenance.

All allegations were found to be unsubstantiated based on staff interviews, record reviews, observations, and documentation. The facility was found to have sufficient supplies, adequate staff training, proper reporting procedures, resident assessments, pest control measures, adequate food service, and proper facility maintenance.

The complaint investigation was unsubstantiated. Allegations included insufficient supplies for resident hygiene and infection control, inadequate staff training, failure to follow reporting requirements, failure to evaluate changes in resident condition, pest issues, inadequate food service, and poor facility maintenance. None of these allegations were substantiated based on evidence gathered.

An unannounced complaint investigation was conducted due to an allegation that the licensee is not ensuring that the facility elevator is maintained in good repair.

The investigation found that elevator two has been out of service since November and remains nonoperational despite management's efforts to repair it. The allegation was substantiated, posing an immediate health and safety risk to persons in care.

The allegation that the licensee is not ensuring the facility elevator is maintained in good repair was substantiated. An immediate civil penalty of $250 was assessed for a repeat violation. Failure to submit proof of correction by the plan of correction due date and any repeat violation within 12 months may result in further civil penalties.

An unannounced complaint investigation was conducted in response to an allegation that the facility does not have sufficient staff to meet residents' needs in the provision of food services.

The investigation found that there is sufficient staff for food service and no resident requires assistance with feeding. The allegation was determined to be unsubstantiated due to lack of evidence.

The complaint alleged insufficient staffing for food services. The investigation included interviews and record reviews, concluding the allegation was unsubstantiated.

An unannounced complaint investigation was conducted in response to allegations that the facility does not employ a qualified food service consultant and that disaster drills are not being conducted as required.

The investigation found that the facility employs a qualified full-time food service employee and a dietician, and disaster drills are conducted monthly and properly logged. Both allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unannounced and conducted based on allegations received on 2025-04-17. Both allegations were found unsubstantiated after interviews and record reviews.

The visit was an unannounced office meeting conducted to verify a Chapter 7 Bankruptcy Report filed by Pacifica Senior Living as reported by the media.

The meeting confirmed multiple lawsuits involving Pacifica Senior Living management companies, including a $25M lawsuit in Bakersfield and others related to photography and a Skilled Nursing Facility. It was stated that these lawsuits had no financial impact on the properties, residents, or staff, and there were no vendor issues. Management communicated changes to staff and residents, and the bankruptcy did not affect the communities as Pacifica Senior Living was no longer the management company.

An unannounced complaint investigation was conducted due to an allegation that staff did not ensure the facility elevator was properly operating.

The investigation found that although the elevator had been closing on residents, no injuries were reported and the elevator was being repaired at the time of the visit. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility elevator was in disrepair. Interviews with residents and staff, and observation of the elevator repair technician were conducted. The allegation was found unsubstantiated.

An unannounced complaint investigation was conducted due to an allegation that the facility elevator is in disrepair.

The investigation found the allegation unsubstantiated as the elevator was in the process of being repaired with documented plans and a reasonable timeline for completion.

The complaint alleged that the facility elevator was in disrepair. The investigation included interviews with the Executive Director and residents, and review of service and maintenance logs. It was determined the elevator was being repaired and there was no preponderance of evidence to substantiate the allegation.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff mismanaged a resident's medication.

The investigation included interviews and review of medication records and logs. The allegation of medication mismanagement was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff mismanaged a resident's medication. The investigation reviewed R1's MAR, medication count sheet, physician report, care plan, and medication staff communication log. Medication was removed from the facility before verification. The allegation was unsubstantiated.

The inspection was conducted as a 10-day initial complaint investigation regarding an allegation that the facility's Disaster Plan does not meet Regulation Requirements.

The investigation found the allegation unsubstantiated after review and interview, confirming that the Disaster Plan was current and met regulatory requirements.

The complaint alleged that the facility’s Disaster Plan was out of compliance, specifically that the Evacuation component had an expired date. The investigation found no evidence to substantiate this claim.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-04-26 concerning resident rights and care at Lake Park Senior Living Facility.

The investigation substantiated allegations that staff did not provide the resident's authorized representative with records in a timely manner and did not provide the resident with privacy. Other allegations including falsification of appraisal documentation, lack of assistance with hygiene and laundry, and an uncomfortable environment were found unsubstantiated.

The complaint investigation was substantiated for allegations that staff did not provide resident’s authorized representative with records and did not provide resident with privacy. Other allegations were unsubstantiated. The investigation included interviews, record reviews, and observations conducted by Licensing Program Analyst Laura Hall.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-02-20 regarding allegations including the facility being in financial distress and plumbing disrepair.

The allegation that the facility is in financial distress was substantiated based on interviews, document reviews, and observations showing unpaid utility bills and contractor invoices. The plumbing disrepair allegation was unsubstantiated due to lack of sufficient evidence. No deficiencies were cited for plumbing, but a financial deficiency was cited related to failure to maintain sufficient resources to meet operating costs.

The complaint investigation was substantiated for the allegation of financial distress, with evidence including past due utility bills from PG&E and Waste Management, unpaid contractor invoices totaling $42,800 for sewer lateral repairs, and non-payment for pest and caregiver services. The plumbing disrepair allegation was unsubstantiated after interviews and review of maintenance work completed in 2023.

The inspection was an unannounced continuing complaint investigation visit conducted due to allegations that the facility was not complying with its approved plan of operation and that staff mismanaged a resident's medication.

The allegation that the facility was not complying with the approved plan of operation was substantiated due to conflicting language in the electronic admission agreement. The allegation of staff mismanaging a resident's medication was unsubstantiated due to lack of sufficient evidence. No new deficiencies were issued during this visit due to previous substantiation and deficiencies cited on 7/25/2024.

The complaint investigation included two allegations: 1) Facility not complying with approved plan of operation, which was substantiated; 2) Staff mismanaged resident's medication, which was unsubstantiated. The investigation involved interviews with staff and review of relevant documentation. The medication mismanagement allegation could not be substantiated because the medication was removed from the facility and exact pill counts could not be verified.

The inspection was an unannounced 1-Year Annual Required inspection conducted by Licensing Program Analysts to evaluate compliance with regulatory standards.

The facility was toured and inspected, including resident and staff records review. No deficiencies were observed or cited during the visit. Safety equipment and environmental conditions were found to be in proper working order.

The inspection was an unannounced complaint investigation visit triggered by allegations including inadequate staff training and insufficient staffing at the facility.

The investigation substantiated allegations that facility staff were inadequately trained and that there was insufficient staffing during the night shift, posing health and safety risks. Two other allegations regarding failure to perform required annual re-appraisals and lack of a required dietician were found unsubstantiated.

The complaint investigation was substantiated for allegations of inadequate staff training and insufficient staffing. The allegations regarding failure to perform required annual re-appraisals and lack of a required dietician were unsubstantiated.

An unannounced Case Management visit was conducted on 11/22/2024 to follow up on a complaint investigation (#15-AS-20240503094454) regarding visitor sign-in procedures and resident safety.

The facility was found not requiring visitors to sign in and allowing them to access residents' apartments without signing in, posing a potential safety and personal rights risk to residents.

The visit was complaint-related, investigating complaint #15-AS-20240503094454. The complaint was substantiated as the facility was found not requiring visitor sign-in, exposing residents to personal rights violations.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff interfered with the designation of a responsible person for a resident.

The investigation found insufficient evidence to substantiate the allegation. The previous Executive Director followed appropriate procedures by contacting the resident's emergency contact and other relevant parties, and did not interfere with the designation of the responsible person. The allegation was determined to be unsubstantiated.

The complaint alleged staff interference with the designation of a responsible person for a resident. The investigation included interviews, record reviews, and document analysis. The allegation was found to be unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was overcharging a resident.

The investigation substantiated the allegation that the facility charged a resident a $50.00 fee for insufficient funds (NSF) which was not reversed, despite the resident having sufficient funds and no bank charge for NSF. The facility reversed a $250.00 late payment charge but refused to reverse the $50.00 NSF fee.

The complaint was substantiated based on interviews and records review. The resident stated they had sufficient funds and no bank charge for NSF. The facility was found to have improperly charged the resident $50.00 for NSF. The deficiency is cited under Title 22 California Code of Regulations section 87468.2(a)(8).

The visit was an unannounced Case Management inspection conducted as part of a complaint investigation regarding the facility's surety bond status and resident cash management.

No deficiencies were issued during the visit. The Executive Director confirmed the facility does not hold residents' cash, which may be managed by fiduciaries or bankers.

The complaint investigation was triggered by information received on 09/17/2024 that the management and ownership did not have a surety bond.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-02-12 regarding staff not ensuring a healthful environment and inadequate food services for residents.

The investigation found no preponderance of evidence to substantiate the allegations; the complaint was determined to be unsubstantiated after interviews and review.

The complaint alleged that staff were not ensuring a healthful environment and that the licensee did not provide adequate food services. The investigation included interviews with the reporting party and residents, who stated the food issue had been resolved. The allegations were unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that staff did not provide safe transportation for a resident.

The investigation found that residents who are wheelchair-bound were not transported by facility staff using the facility's vans because it was impossible to accommodate wheelchairs in the vans. Transportation for wheelchair-bound residents was arranged through a sister facility or a private company. The allegation was closed as unsubstantiated due to insufficient evidence to prove the violation occurred.

The complaint alleged that staff did not provide safe transportation for a resident. The complaint was investigated and found to be unsubstantiated.

The inspection was conducted as an unannounced complaint investigation regarding allegations that the facility changed its Plan of Operation without Community Care Licensing Division (CCLD) approval.

The investigation substantiated that the facility changed its Plan of Operation to lease units to 55+ independent renters and Section 8 recipients without CCLD approval, which is a significant change affecting resident services and poses potential health, safety, or personal rights risks.

The complaint alleged that the facility changed the Plan of Operation without CCLD approval. The allegation was substantiated based on interviews, observations, and record reviews.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee did not adhere to the terms and conditions of the Admission Agreement, specifically regarding the provision of 24-hour security service.

The investigation substantiated the allegation that the facility failed to provide the 24-hour security service as required by existing Continuing Care Retirement Community (CCRC) contracts, posing a potential health, safety, and personal rights risk to residents. The facility had discontinued dedicated security guard services and non-operational security cameras due to non-payment since Spring 2023.

The complaint was substantiated. The allegation was that the licensee did not adhere to the terms and conditions of the Admission Agreement, specifically the provision of 24-hour security service. Interviews with staff, residents, and witnesses confirmed the lack of dedicated security personnel, non-operational security cameras, and unsecured facility entrances, which violated the terms of the CCRC contracts.

The visit was conducted as a Case Management visit and complaint investigation regarding concerns about food availability for residents reported on 05/26/2024.

During the complaint investigation, it was observed that adequate food was available for residents, and no deficiencies were issued during the visit.

The complaint investigation was related to questionable food availability for residents. The complaint was not substantiated as adequate food was found during the visit.

An unannounced complaint investigation was conducted due to an allegation that staff did not get the proper permits for renovation in the facility.

The allegation was substantiated. The investigation found that the facility replaced kitchen equipment and moved gas lines without obtaining the required building permit, posing a potential health and safety risk to residents.

The complaint was substantiated based on evidence that the facility did not obtain the required permits for renovation involving gas line changes and equipment replacement.

An unannounced complaint investigation was conducted to investigate allegations that staff did not adhere to a resident's admissions agreement, specifically regarding the failure to replace a broken refrigerator in a resident's unit.

The investigation found that four out of five residents interviewed had refrigerators in their units in working condition, and one resident whose refrigerator was not working had it replaced immediately without charge. The refrigerators inspected were observed to be operating. The allegation was closed as unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility failed to replace a broken refrigerator as required by the admissions agreement. The complaint was investigated and found unsubstantiated.

An unannounced complaint investigation visit was conducted regarding an allegation that the facility has pests.

The investigation found that although pests were present in the kitchen, the issue had been addressed with pest control services. Multiple traps were observed and pest control visits had recently resumed. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated after investigation. Pest presence was acknowledged but addressed with pest control company Clark, which recommended weekly visits to eliminate the issue. The Executive Director approved the recommendation.

The visit was an unannounced Proof of Correction (POC) inspection to verify correction of previously cited deficiencies related to billing and payment status for PG&E and Waste Management accounts.

The deficiencies related to unpaid accounts were cleared as the facility demonstrated that PG&E and Waste Management accounts were current and paid through March 2024. An exit interview was conducted and a Letter of Deficiency Citations Cleared was provided.

The visit was a Case Management conducted while at the facility for another matter, related to a prior complaint investigation.

No citations were issued during this visit. The Licensing Program Analyst reviewed documents related to non-payment for caregiver services and other accounts, and conducted an exit interview.

The visit referenced a prior complaint investigation (#15-AS-20240220153014) conducted on 2024-02-21 involving non-payment for caregiver services and related invoices.

The visit was an unannounced Case Management visit related to complaint 15-AS-2024 0220153014, focusing on obtaining documents and information about the payment history for utility accounts and service vendors.

The facility failed to provide requested accounting documents related to gas, electricity, and waste collection services, resulting in cited deficiencies for noncompliance with California Code of Regulation, Title 22, posing an immediate health and safety risk.

The visit was related to complaint 15-AS-2024 0220153014. The facility did not provide requested documents despite multiple requests on 2/21/24, 2/28/24, 2/29/24, 3/1/24, 3/11/24, 3/12/24, and 3/13/24.

An unannounced Health and Safety check was conducted to assess utilities operation, cleanliness, garbage buildup, and resident well-being.

The facility was found to be clean with no imminent health and safety concerns. Residents appeared safe and no deficiencies were cited during the visit.

An unannounced Case Management visit was conducted to gather information regarding the facility's intent to rent units to independent 55+ individuals and persons with Section 8 Vouchers, and to clarify policies about Physician’s Reports and Tuberculosis tests for these residents.

No citations were issued during this visit. The Licensing Program Analyst met with the Executive Director and obtained relevant documents including lease agreements and rental applications. An exit interview was conducted and a copy of the report was provided.

An unannounced complaint investigation visit was conducted on 02/16/2024 concerning allegations that staff did not ensure the facility restrooms were equipped with grab bars, had toiletries, and were kept clean.

The investigation found that although there were no ADA-compliant grab bars currently in the public restrooms due to supply delays, the facility planned to complete updates by the end of February 2024. The restrooms did have toiletries and were kept clean. There was insufficient evidence to substantiate the allegations, and the complaint was unsubstantiated.

The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the allegations regarding restroom grab bars, toiletries, and cleanliness.

An unannounced complaint investigation visit was conducted on 02/09/2024 concerning allegations that staff were not following a resident's care plan and that the facility was in disrepair.

The investigation found both allegations to be unsubstantiated. Staff interviews and review of shower logs showed no disruption in resident care or facility services during renovations.

The complaint investigation was unsubstantiated based on evidence gathered, including staff interviews and documentation review. Allegations included staff not following resident's care plan and facility disrepair.

Unannounced complaint investigation visit conducted due to allegations received on 2024-01-29 regarding facility disrepair, cleanliness, and safety concerns for residents.

The allegation that the facility is in disrepair was substantiated due to unrepaired security doors posing a safety risk. Allegations that the facility was unclean and that staff did not provide a safe environment were unsubstantiated after interviews and facility tours.

The complaint investigation was substantiated for the allegation of facility disrepair related to security doors. The allegations of uncleanliness and unsafe environment were unsubstantiated based on interviews and observations.

An unannounced initial 10-day complaint investigation was conducted to assess compliance with emergency drill requirements.

The facility was found not to be conducting required quarterly emergency drills for each shift, as evidenced by lack of documentation and statements from residents and staff.

The visit was complaint-related and involved an unannounced initial 10-day complaint investigation. The deficiency was substantiated based on evidence and statements.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility illegally evicted a resident and hired an aide for a resident without obtaining consent.

The investigation substantiated that the facility illegally evicted a resident who developed memory care needs despite contracts stating such residents should be retained. Additionally, the facility failed to provide required advance written notice regarding the need and costs for a 24-hour 1:1 aide.

The complaint investigation was substantiated. Allegations included illegal eviction of a resident and hiring an aide without consent. The facility was found to have violated continuing care contract obligations and failed to issue required notices.

Unannounced complaint investigation visit conducted in response to an allegation that a staff person entered a resident's unit by force without authorization.

The allegation was found to be unsubstantiated after interviews with involved parties and witnesses. No deficiencies were cited during the visit.

Allegation: Staff person entered resident's unit by force without authorization. Investigation included interviews with resident R1, staff S1 and S2, and resident R2. All evidence indicated no forced entry occurred; the resident had made an appointment and welcomed staff into the unit.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-12-05 regarding staff not maintaining the facility in good repair.

The investigation found that there was a known heating issue in the building with repairs scheduled, but the complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

The complaint alleged that staff did not maintain the facility in good repair. The investigation included interviews and document review. The heating issue was acknowledged but was being addressed. The allegations were unsubstantiated due to insufficient evidence.

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff does not ensure planned activities are posted in a readily accessible location for residents.

The investigation found the allegation to be unsubstantiated after touring the facility, reviewing records, and interviewing staff. Planned activities were observed to be posted in accessible locations and additional copies were available for residents.

The complaint allegation that facility staff does not ensure planned activities are posted in a readily accessible location for residents was investigated and found to be unsubstantiated.

The visit occurred as a Case Management - Other type of visit, during which the Licensing Program Analyst toured the facility with the Executive Director to observe renovations and verify compliance with permit requirements.

The facility was observed to be clean, bright, and in good repair with no deficiencies cited during the inspection. Remodelled areas were sectioned off to ensure residents were not impacted by renovations, and a permit was secured for new bathroom tiles.

An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2023-01-30 regarding facility disrepair, transportation, nutrition, temperature comfort, and adherence to residents' admission agreements.

All allegations investigated were found to be unsubstantiated due to lack of preponderance of evidence proving violations. The facility was found to have operational elevators (except one broken since November 2022), available transportation options, adherence to nutritional guidelines, temperature issues resolved, and compliance with residents' admission agreements.

The complaint investigation was unsubstantiated. Allegations included facility disrepair, failure to provide appropriate transportation, failure to provide nutrition food service to meet residents' needs, failure to provide a comfortable temperature, and failure to adhere to residents' admission agreement. Each allegation was investigated and found unsubstantiated.

An unannounced case management health and safety check was conducted to assess the facility's conditions and compliance.

The facility was undergoing renovations but maintained safety and cleanliness. Adequate food supplies, PPE, staffing, and safe environment were observed. No deficiencies were cited during the inspection.

The inspection visit was a Post-Licensing unannounced inspection conducted to evaluate the facility's compliance following licensing.

The facility was found to be in compliance with no deficiencies cited. Observations included proper COVID-19 screening and infection control measures, adequate food and PPE supplies, and the presence of required plans and records.

The visit was an unannounced case management health and safety check conducted by the Licensing Program Analyst.

The facility was found to have adequate food, PPE, and emergency supplies, sufficient staffing, and no imminent health or safety concerns. Staff were observed wearing surgical masks and infection control posters were posted.

An unannounced case management health and safety check was conducted to assess the facility's compliance with health and safety standards.

The inspection found adequate food, PPE, and staffing levels, proper COVID-19 symptom screening, and no imminent health or safety concerns. Staff and residents reported no noticeable changes in service or schedules.

The visit was an office evaluation related to a Change of Ownership application for the Residential Care Facility for the Elderly with Continuing Care Retirement Community.

The applicant/administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.

A virtual meeting was conducted pertaining to the licensure application pending for Lake Park Senior Living and Pacific Grove Senior Living to review licensing expectations and requirements.

The Department reviewed expectations including staffing, facility oversight, and quality assurance audits with the applicants. The applicant agreed to the listed conditions and acknowledged licensing appeal rights.

The visit was conducted as a case management inspection and included a pre-licensing inspection due to a change of ownership.

The Licensing Program Analysts conducted an unannounced case management visit and pre-licensing inspection, noting that the pre-licensing inspection was initially conducted under the old facility number and corrected to the new facility number. An exit interview was conducted and a copy of the report was provided.

The inspection was conducted as a pre-licensing visit due to a change of ownership at the facility.

No issues were noted during the inspection. The Licensing Program Analysts observed that the facility is ready to be licensed, subject to final approval by the Central Applications Unit.

report_49_19201182_inx48_2025-04-22.pdf

report_24_19201182_inx23_2024-02-01.pdf