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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606651
Report Date: 03/23/2021
Date Signed: 03/23/2021 04:57:41 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
08/18/2020 and conducted by Evaluator LaJean Nicole Spencer
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200818142529
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: 50DATE:
03/23/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jeanne de CastroTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained unexplained injury while in care
Facility failed to report incident to resident's representative
Facility failed to report incident to licensing and LTCO
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicole Spencer initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Jeanne de Castro, the assistant administrator.
During the initial visit on 8/26/20, LPA Spencer conducted telephone interviews with the assistant administrator Jeanne de Castro, staff #1 (S1), and resident #1 (R1) and conducted a video call to tour the physical plant. The LPA obtained copies of the staff roster, resident roster, staff contact number list, and for R1: the Needs and Servies Plan, face sheet, physician's report, caregivers notes from 8/17/20, nurse practitioner notes for 8/18/20, body assessment charts, medications log, history of falls, daily monitoring charts, SIR's, discharge papers, and photos of the resident's face from 8/11, 8/15, and 8/18. During the course of the investigation, LPA Spencer conducted telephone interviews with the administrator, R1's nurse practitioner, staff #2-5 (S2-S5), residents # 2-8 (R2-R8), and family members of R1. **See continuation of narrative on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20200818142529
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: 03/23/2021
NARRATIVE
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LPA interviewed 7 staff and 8 residents. R1, R2, and R4 were unable to complete interviews, so 5 residents interviews were completed. The investigation revealed the following:
Resident sustained unexplained injury while in care
R1's durable power of attorney (DPOA) visited R1 on 8/15/20 through a window and noticed bruising below R1's left eye. She took pictures and provided copies of the photo to the Long Term Care Ombudsman (LTCO) and licensing. A review of the photo taken on 8/15 shows yellow and purple bruising under the left eye. A photo of R1 on 8/11 shows no bruising on the face, indicating that the bruising occurred between 8/11-8/15. The facility photos dated 8/18/20 shows healing bruising on R1's face. The assistant administrator admitted that she was not aware of the bruising on R1's eye until contacted by the LTCO on 8/17. She stated that she did not know how the bruising occurred. The LTCO staff interviewed stated that the facility admitted to not knowing how the bruising occurred but provided pictures of R1 face. All residents interviewed stated that they were unaware of a resident having bruising under the eye. 6 out of 7 staff stated that they were unaware of the bruising under R1's eye or how it happened. LPA reviewed the body check assessment dated 8/12 and 8/17 and it stated that R1's body was clear. Assistant administrator stated that caregivers usually check the body and not the face. A virtual health check-up with R1 was conducted with nurse practitioner (NP) on 8/18/20 which noted mild bruising and discoloration of the skin.
Facility failed to report incident to resident's representative
The review of records showed that R1's DPOA's are the resident's daughter and husband. DPOA's stated that the bruising was not reported and instead the facility denied that there was bruising on R1's eye on 8/17/20. The caregiver's notes on 8/17/20 state that DPOA inquired about the bruise but that it appeared to be an age spot. The caregivers notes stated that the bruising was reported to R1's NP during the health check-up. NP attempted to contact DPOA's on 8/18/20 and left a message. Assistant administrator said that the facility did not contact R1's DPOA because the NP already informed them.
Facility failed to report incident to licensing and LTCO
The assistant administrator admitted that the incident was not reported to licensing and LTCO because the facility was not initially aware of the bruising. When facility was made aware of the bruising, the assistant administrator stated that an incident report was not sent based on NP assessment of the bruise, which was classified as mild bruising and discoloration of the skin. An incident report regarding NP visit was not sent.
Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. CCR Title 22, Division 6, Chapter 8 is being cited on attached LIC9099D. An exit interview was conducted and copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20200818142529
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2021
Section Cited
CCR
87466
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87466 Observation of the resident: The licensee shall ensure that residents are regularly observed for changes in physical...functioning and that appropriate assistance is provided when such observation reveals unmet needs. This was not met as evidenced by:
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An in-service training will be conducted with caregivers regarding completing body assessments. Facility will submit training log to CCL by 4/2/2021.
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Based on interviews and record review, the licensee did not ensure that body check assessments for R1 was thoroughly completed to identify bruising and discoloration on R1's face. This poses a potential health and safety risk to persons in care.
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Type B
03/23/2021
Section Cited
CCR
87466
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87466 Observation of the resident: When changes such as...a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This was not met as evidenced by:
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An in-service training will be conducted with medtechs regarding reporting to responsible parties. Facility will submit training logs to CCL by 4/2/2021.
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Based on interviews and record review, the licensee did not report the unexplained injuries to R1's responsible party.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20200818142529
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2021
Section Cited
CCR
87211(a)(1)(B)
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87211(a)(1)(B) Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require including...any serious injury...This requirement was not met as evidenced by:

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An in-service training will be conducted for medtech staff regarding reporting requirements. The facility will submit training logs to CCL by 4/2/2021.
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Based on interviews and record review, the licensee did not submit an incident report to the Department regarding the bruising and discoloration under R1's left eye within 7 days.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4