197606651-3-3-2023-28-AS-RORN-CPQPLG-20230308102443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606651
Report Date: 03/03/2023
Date Signed: 03/03/2023 11:18:56 AM

Unsubstantiated

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
01/05/2022 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220105091250

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: 62	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Assistant Administrator Jeenne DeCastro		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained unexplained fracture while in care
Facility did not seek timely medical attention for a resident in care
Facility did not notify resident’s representative of unusual incident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent complaint visit to the facility and was greeted by Assistant Administrator Jeene DeCastro and the reason for the visit was explained.
The purpose of the visit is to deliver findings for the above allegations.
The initial visit was conducted on 01/06/2022 in which a Health and Safety Check was conducted.
Subsequent visit was conducted on 11/21/2022 in which the following was done:
At 10:00 A.M. a tour of the facility was conducted which included 75 Resident Bedrooms, 2 Activity Rooms, 2 Dining Rooms, 2 outdoor patios, dining room, kitchen and medication room.
File for Resident R 1 was reviewed and various documents were submitted from the file.
At today's visit Assistant Administrator Jeenne DeCastro was interviewed at 9:15 AM.
At 9:30 AM Staff S 1 was interviewed telephonically.
An investigation was conducted by the Investigations Branch (IB) Investigator Olivia Spindola from the Department of Social Services and completed 2/28/2023 and included the following:
Obtaining and reviewing documents from the facility, interviews with facility staff members, Special Incident

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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-20220105091250

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: 03/03/2023

NARRATIVE

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Report's (SIR's), Physician's Report, medical records from PIH Downey, Southland Care, Kindred Hospital and review of documentation by Program Clinical Consultant Department of Social Services and interviews with residents and physician.
In regards to the allegation Resident sustained unexplained fracture while in care, based on interviews conducted and information gathered there was no witnessed fall for R 1 and based on medical records and witness statements the fall was unforeseen.
R 1 was under the Assisted Living Waiver Program and Individual Service Plan updated every 6 months.
As part of the Waiver Program Home Health conducted monthly visits to assess R 1.
Home Health identified and documented service plans including. but not limited to Risks for falls/injury, activity intolerance, impaired skin integrity and Dementia and forgetfulness.
Based upon interviews and records reviewed, the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

In regards to the allegation Facility did not seek timely medical attention for a resident in care, based on interviews conducted and information gathered R 1 received medical care from PIH Downey, Soutthland Care, and physician for R 1. R 1 most likely suffered a hip fracture from an unwitnessed fall and was transported for medical care on 11/06/2021 at 1400 hours. R 1 was transferred via ambulance to PIH Downey as soon as it was identified by staff. R 1 was in a wheelchair and vital signs were checked and assessed for pain. R 1 was under the Assisted Living Waiver Program and Individual Service Plan updated every 6 months. As part of the Waiver program Home Health conducted monthly visits to assess R 1. Home Health identified and documented service plans including. but not limited to Risks for falls/injury, activity intolerance, impaired skin integrity and Dementia and forgetfulness.

Based upon interviews and records reviewed, the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

In regards to the allegation Facility did not notify resident’s representative of unusual incident, based on interviews conducted and information gathered staff interviewed stated that regarding R 1 the protocol if there are falls or any need for a resident to go to the hospital the family is immediately notified and also the physician. Staff stated that this was the only time that R 1's family member was notified that R 1

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220105091250

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: 03/03/2023

NARRATIVE

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needed to go to the hospital as there were no witnessed falls previous to 11/06/2021.
Staff stated that client notes were documented 11/06/2021 stating that family member, physician and assistant administrator was informed when R1 had hip pain and an ambulance picked her up.
LPA observed client notes stating that family was notified 11/06/2021 and also family member had called the facility at 10:30 PM with a status update.

Based upon interviews and records reviewed, the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

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