Inspection Reports for
Lake Park Senior Living

The visit was related to complaint 15-AS-20241030085123; no deficiencies were cited during this amended report delivery.

No deficiencies were cited during the visit. The Licensing Program Analyst met with the Executive Director, explained the purpose of the visit, and signed and printed the amended report.

The inspection found no deficiencies; all areas including resident and staff records were complete, safety equipment was operational, and environmental conditions were adequate.

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.

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 facility reported multiple lawsuits involving Pacifica Senior Living management, including a $25 million lawsuit in Bakersfield, a photography lawsuit, and a lawsuit against a Skilled Nursing Facility in Healdsburg. Despite these lawsuits, the CEO stated there was no financial impact on the properties, residents, or staff, and 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.

The allegation was that the facility elevator was in disrepair. Interviews with residents and staff, and observation of the elevator repair technician, led to the conclusion that the allegation was unsubstantiated.

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. There was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.

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

The complaint investigation included two allegations: 1) Facility not complying with approved plan of operation, which was substantiated with no new deficiencies issued due to prior substantiation and deficiencies cited on 7/25/2024; 2) Staff mismanaged resident's medication, which was unsubstantiated due to insufficient evidence.

The allegation that the facility was not complying with the approved plan of operation was substantiated due to the use of an incorrect electronic admission agreement mixing language for independent individuals and licensed RCFE residents, previously substantiated on 7/25/2024. The allegation of staff mismanaging a resident's medication was unsubstantiated due to lack of sufficient evidence.

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

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 visit was related to a complaint investigation (15-AS-20240811203347) concerning the lack of a surety bond by Northstar management and Pacifica ownership, reported on 09/17/2024.

No deficiencies were issued during the visit. The Executive Director confirmed that the facility does not hold residents' cash and that residents may have fiduciaries or bankers managing their money.

The complaint alleged staff were not ensuring a healthful environment and inadequate food services. The complaint was unsubstantiated after investigation.

The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove them; therefore, the allegations were unsubstantiated. The food service issue was reported resolved by residents and the reporting party.

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

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

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 was unsubstantiated as there was insufficient evidence to prove the allegations of pests at the facility.

The investigation found that while there were pests in the kitchen, the issue had been addressed with pest control services. Multiple traps were observed and pest control company Clark had recently started weekly visits. The allegations were unsubstantiated due to lack of preponderance of evidence.

The prior complaint investigation (#15-AS-20240220153014) on 2024-02-21 involved interviews and review of documents related to non-payment for caregiver services and other accounts.

No citations were issued during this visit. The Licensing Program Analyst reviewed documents related to non-payment for caregiver services and other accounts during the prior complaint investigation.

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.

The complaint investigation was unsubstantiated. Allegations included lack of restroom grab bars, toiletries, and cleanliness. Observations and interviews did not support these allegations.

The investigation found that although there were no ADA-compliant grab bars in the public restrooms, this was due to supply delays during renovations expected to be completed by the end of February 2024. The restrooms did have toiletries and were kept clean. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

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.

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 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 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 facility was observed to be clean, bright, and in good repair with no deficiencies cited during the inspection. Remodelled areas were sectioned off to prevent impact on residents, and a permit was secured for new bathroom tiles.

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.

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 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 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 facility was found to be in compliance with no deficiencies cited. The evaluator observed proper COVID-19 screening, PPE use, sufficient food and supply stocks, and appropriate plans and records in place.

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.

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 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.

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 Department reviewed expectations including corporate liaison responsibilities, staffing requirements for memory care units, and facility administrator oversight. The applicant agreed to the listed conditions and acknowledged potential increased inspections for monitoring purposes.

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.

No issues were noted during the inspection. The facility was observed to be ready for licensing, with all areas and equipment meeting requirements. The report will be submitted for final review and approval.