198602950-2-4-2022-28-AS-LHIS-CCQU8N-20220321152148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:19:05 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
01/28/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220128150605

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: 107	DATE:	02/04/2022
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Cynthia Flores, Assistant Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Neglect and lack of supervision resulting in fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with Assistant Administrator Cynthia Flores. Administrator Lisa Pham was explained the purpose of the visit and interviewed telephonically.

The investigation consisted of: Staff (S1-S7) and residents (R2 - R10) were interviewed. An interview was attempted with resident (R1). Family (F1) was interviewed. Resident (R1's) file was reviewed. The following documents were obtained: Identification and Emergency Information/Residents Face Sheet, Physician Reports, Appraisals, Individual Service Plan (ISP), Incident report dated 1/27/2022, Admission Agreement, resident roster, and LIC 500 Personnel Report were obtained.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

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-20220128150605

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: 02/04/2022

NARRATIVE

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Allegation: "Neglect and lack of supervision resulting in fracture." Based on record review and interviews conducted the findings indicate that on January 27, 2022 at approximately 9:00 AM, 98 year-old resident (R1) had an un-witnessed fall in the room. It is unknown how long the resident was on the floor. Staff (S4) found the resident on the floor next to the night stand. A body check was conducted, and at first the resident did not report major pain or discomfort. Caregiver checked on the resident approximately 2 hours later, and the resident then reported knee pain and discomfort. The resident was then transported to Norwalk Community Hospital approximately 4 hours later. Resident (R1) sustained a knee fracture and is presently recuperating at a Skilled Nursing Facility.

Staff stated R1 is overall independent, uses a walker, and requires minimal assistance. However, per Individual Service Plan (ISP) resident (R1) is at fall risk. Staff reported caregivers perform room checks every 2 hours. All staff interviewed denied negligence or lack of supervision in regards to R1's fall incident. Three (3) out of nine (9) residents stated staff do not perform regular room checks and there is not enough staff supervision. Family has not had any concerns with resident (R1's) care. There is insufficient evidence to support the allegation.

Based on record review and interviews conducted 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 occurred, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Assistant Administrator Cynthia Flores. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

LIC9099 (FAS) - (06/04)

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