198602950-10-14-2021-28-AS-CYEE-C8V4SJ-20211117182134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 10/13/2021
Date Signed: 10/14/2021 05:28:35 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
04/16/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210416111501

FACILITY NAME:	LAKEWOOD PARK MANOR		FACILITY NUMBER:	198602950
ADMINISTRATOR:	LISA PHAM		FACILITY TYPE:	740
ADDRESS:	12045 LAKEWOOD BLVD		TELEPHONE:	(562) 923-4417
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY:	160	CENSUS: 108	DATE:	10/13/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Cynthia Flores, assistant administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Black mold at the facility.
Resident was injured while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***Please note: this LIC9099 report supercedes LIC9099 report dated 7/2/21. Additional interviews were conducted but the findings remain the same.***

Licensing Program Analyst (LPA) Spencer conducted a visit to supercede the report dated 7/2/21 for the allegations listed above. LPA Spencer was met by assistant administrator Cynthia Flores and explained the purpose of today's visit. The investigation consisted of the following: On 4/21/21, LPA Spencer conducted the initial investigation, took a tour of the physical plant, and conducted interviews with assistant administrator Cynthia Flores, staff #1 (S1), and residents #2-5 (R2-R5). On 7/2/21, LPA Spencer interviewed the facility's elevator service repair company (W1), staff #2 (S2), resident #1 (R1) and residents #6-11 (R6-R11). R4-R5 declined to be interviewed so a total of 9 resident interviews were conducted. On today's visit, LPA interviewed staff #3-staff #4 (S3-S4) and a follow-up interview with the assistant administrator.
***See LIC9099C for continuation of this narrative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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 2

Control Number 28-AS-20210416111501

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 PARK MANOR	FACILITY NUMBER: 198602950
	VISIT DATE: 10/13/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Spencer collected a copy of the staff roster, resident roster, elevator service invoices from 12/2019-6/2020 and R1's needs and services plan. Per assistant administrator, there were no hospital records or incident reports regarding R1.

The investigation revealed the following:
Black mold at the facility: It was alleged that there was black mold throughout the facility that lead to residents hospitalizations/deaths. During LPA Spencer's tour of the physical plant on 4/21/21 and 7/2/21, LPA did not observe any signs of black mold in the kitchen, dining rooms, common areas, bathrooms, or resident rooms. In interviews, the assistant administrator denied the allegation of black mold and hospitalizations/deaths due to black mold. Three (3) out of four (4) staff interviewed denied that the facility has been treated for black mold and have not observed any black mold at the facility. One (1) out of four (4) staff stated that they have observed black mold in a couple of resident bathrooms but that it was immediately treated with bleach. Staff interviewed had no knowledge of any resident hospitalization/death due to black mold. Eight (8) out of nine (9) residents interviewed stated that they have never noticed black mold or heard of any resident hospitalizations/deaths due to black mold.
Resident was injured while in care: It was alleged that a resident was injured by a fallen elevator ceiling that was damaged by an earthquake that occurred in 2019. During LPA Spencer's observation of the two facility elevators on 4/21/21 and 7/2/21, LPA did not observe any signs of damage to the elevators. During interviews, all staff denied the allegation that a resident was injured by the elevators. Staff stated that regular maintenance is conducted on elevators on a monthly basis. A review of elevator service invoices from 12/2019-6/2020 show that standard maintenance was completed on the elevators monthly. In interview with the elevator service repair company, W1 stated that only regular maintenance was completed and the system doesn't show that any ceiling damage was documented. 8 out of 9 residents interviewed stated that they had no knowledge of a resident being injured by the elevators and do not recall an earthquake causing damage to the elevators.

Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are 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. An exit interview was conducted with assistant administrator and a copy of the report was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2