197606651-8-12-2020-28-AS-RORN-BUYS5Z-20201102123508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606651
Report Date: 08/07/2020
Date Signed: 08/12/2020 05:05:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/16/2020 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200116080333

FACILITY NAME:	LAKEWOOD GARDENS		FACILITY NUMBER:	197606651
ADMINISTRATOR:	SHOLOM YOSEF GOLDMAN		FACILITY TYPE:	740
ADDRESS:	12055 S. LAKEWOOD BLVD.		TELEPHONE:	(562) 869-4038
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY:	150	CENSUS: 70	DATE:	08/07/2020
		UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:	Jeene DeCastro		TIME COMPLETED:	01:58 PM

ALLEGATION(S):

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Resident sustained an injury while in care.
Facility staff are not providing adequate supervision to residents in care.
Facility staff did not safeguard resident's personal information.

INVESTIGATION FINDINGS:

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*** This is a corrected copy of the LIC 9099/LIC 9099C that was created on 01/24/2020 and the subsequent report provided on 07/20/2020.***
Licensing Program Analyst (LPA) Nicol Wesley conducted an initial 10 day complaint visit on 01/24/2020 and met with Assistant Administrator Jeenne DeCastro to discuss the purpose for the visit.

Investigation consisted of the following: LPA requested a copy of the staff roster, resident roster, hourly monitoring check log, staff work schedule, unusual incident/injury reports, resident ADL/2hour checklist, caregiver notes, and doctors report. LPA reviewed resident #1's file and requested copies of specific documents. LPA also toured entire facility(locked memory care unit), and visited resident #1's room. LPA interviewed staff, resident #1's family members, and attempted to interview resident #1.

Regarding allegation: Resident sustained an injury while in care. During the investigation, LPA Wesley
Continued on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200116080333

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 GARDENS	FACILITY NUMBER: 197606651
	VISIT DATE: 08/07/2020

NARRATIVE

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interviewed staff and the administrator. On 01/08/20 at 7:30 am staff #2 was preparing to assist resident #1 with elements of daily living and observed bump/bruise on the Left side of residents head. During the interview with staff #2, LPA Wesley confirmed what took place. Staff #2 immediately reported what they observed to staff #1 who contacted the Administrator and Power of Attorney(POA). Staff also monitored the bump/bruise on resident #1's head and contacted the medical doctor to examine resident #1. An X-ray was taken to see if there were any internal injuries and the results were negative. LPA Wesley interviewed resident #1's family member and they informed the LPA that they do not suspect that the injury was caused due to any abuse or neglect from the facility staff or other family members coming to visit resident #1, and LPA was also informed by the family member that resident #1 often walks with their eyes closed and runs into objects. Staff #2 also confirmed that on 1/08/20 resident #1 was not found on the floor by a visitor, and also that resident #1's family member was not in the room with the resident and their roommate during the night or in the morning when staff #2 made their rounds and arrived to assist resident #1 with elements of daily living as the facility is locked with delayed egress, therefore there is not sufficient evidence to support the allegation.

Regarding allegation: Facility staff are not providing adequate supervision to residents in care. LPA Wesley interviewed the Administrator, staff, observed the hourly monitor check log, staff work schedule, resident ADL and 2 hour checklist, staff roster, caregiver notes and the investigation revealed that the facility has adequate staff and also provides a 2 caregiver assist when transferring residents to and from the bed, showers, and restrooms as needed. It was reported that resident #1's family member(#2) was in their room with the door closed and lays on their bed with them when they were advised not to be in the room with resident #1 by them self. The investigation revealed/confirmed that resident #1 is in a closely monitored locked facility where staff are consistently making rounds every hour and the resident also shares the room with another resident. The alleged perpetrator who was identified in the complaint is also listed as one resident #1's emergency contacts. Resident #1's family and facility staff had no concerns that this family member will cause harm to the resident. Based on the information provided and the interviews conducted, there is not sufficient evidence to support the allegation, facility staff are not providing adequate supervision to residents in care.

Regarding allegation: Facility staff did not safeguard resident's personal information. LPA Wesley interviewed the Administrator and staff #3. The Administrator informed the LPA that the facility staff are only allowed to provide information about resident #3 to the responsible party/POA. During the interviews with the
Continued on LIC 9099C.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200116080333

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 GARDENS	FACILITY NUMBER: 197606651
	VISIT DATE: 08/07/2020

NARRATIVE

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Administrator and Staff #3 they informed LPA Wesley that another one of resident #1's family members and spouse visited the facility and began asking questions about resident #1 and became angry when staff #3 apologized and informed them that they could not provide them with any of resident #1's personal information as they are not listed as the POA or on the Advance Health Care Directive. The spouse of Resident #1's family member became angry and informed the Administrator that they are a social workers and demanded answers right away. The Administrator requested their name so that she could see if their names appeared as resident #1's contact (the spouse refused) and the Administrator advised the spouse that they are not the assigned social worker that handles Lakewood Gardens matters, and could not provide them with any information regarding resident #1 because it is confidential.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED. There were no deficiencies cited.

A telephonic exit interview was conducted with Jeene DeCastro, and a copy of the LIC 9099/LIC9099C was provided via email to obtain signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020

LIC9099 (FAS) - (06/04)

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