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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606651
Report Date: 01/06/2022
Date Signed: 01/06/2022 04:41:26 PM

Document Has Been Signed on 01/06/2022 04:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LAKEWOOD GARDENSFACILITY NUMBER:
197606651
ADMINISTRATOR:SHOLOM YOSEF GOLDMANFACILITY TYPE:
740
ADDRESS:12055 S. LAKEWOOD BLVD.TELEPHONE:
(562) 869-4038
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 150CENSUS: 69DATE:
01/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jeene De CastroTIME COMPLETED:
04:45 PM
NARRATIVE
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1/6/2022 Licensing Program Analyst (LPA) , Nina Galarza conducted an unannounced Case Management visit. Purpose of the visit was to address deficiencies observed on 1/6/2022 during a complaint investigation. LPA met with assistant administrator, Jeene De Castro and stated the purpose of the visit. LPA toured facility with assistant administrator. LPA was provided Physician's Report for R1.

During the tour the following deficiencies were observed:
  • bathroom in room 40 with a hole in the sink
  • room 35 bathroom with no hot water
  • Disinfectant Spray in resident room 74

During the visit, LPA was not screened for symptoms of COVID-19. LPA is issuing a Technical Violation.

Deficiencies cited under California Code of Regulations, refer 809-D



Exit Interview conducted, copy of report and appeal rights provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2022 04:41 PM - It Cannot Be Edited


Created By: Nina Galarza On 01/06/2022 at 04:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LAKEWOOD GARDENS
FACILITY NUMBER: 197606651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2022
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, ...gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by:
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Assistant administrator removed chemical at time of visit. No further action needed.
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LPA observed Disinfectant Spray in resident room 74. Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
01/07/2022
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and 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.
This requirement is not met as evidenced by:
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Administrator will repair or replace all items and send picture proof to LPA Nina Galarza by POC date
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LPA observed room 35 bathroom with no hot water. LPA observed bathroom in room 40 with a hole in the sink. Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2022


LIC809 (FAS) - (06/04)
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