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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 12/08/2021
Date Signed: 12/08/2021 05:11:54 PM

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
10/06/2021 and conducted by Evaluator LaJean Nicole Spencer
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211006120622
FACILITY NAME:LAKEWOOD PARK MANORFACILITY NUMBER:
198602950
ADMINISTRATOR:LISA PHAMFACILITY TYPE:
740
ADDRESS:12045 LAKEWOOD BLVDTELEPHONE:
(562) 923-4417
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:160CENSUS: 109DATE:
12/08/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cynthia Flores, assistant administratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Residents bathroom is not properly cleaned
Staff did not change resident's bed linens in a timely manner
Resident was put on a 72 hour hold without cause
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent complaint visit for the allegations listed above. LPA Spencer met with assistant administrator Cynthia Flores and explained the purpose of today's visit.

The investigation consisted of the following: During the initial visit on 10/13/21, LPA conducted a tour of the physical plant including a sample of resident rooms and observed meal service. LPA Spencer interviewed the assistant administrator, staff #1-4 (S1-S4), and residents #1-11 (R1-R11). During the course of the investigation, LPA interviewed staff #5-6 (S5-S6). LPA collected a copy of the staff roster, resident roster, menu, cleaning schedule and housekeeping duties. For R1, LPA collected incident reports, police report, physician's report, and admissions agreement.

***See LIC9099C for continuation of this narrative.***
Unsubstantiated
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: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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 8
Control Number 28-AS-20211006120622
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: 12/08/2021
NARRATIVE
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The investigation revealed the following: Regarding the allegation, "residents bathroom is not properly cleaned" it was alleged that resident bathrooms are not thoroughly cleaned due to housekeeping not mopping floors and cleaning the toilets. Interviews with residents revealed: nine (9) out of eleven (11) residents stated that bathrooms are thoroughly cleaned including cleaning sinks, toilets, showers, and mopping. Two (2) out of eleven (11) residents stated that bathrooms are not thoroughly cleaned. Interviews with staff reveal that housekeeping staff cleans the toilets, take out the trash, mop, sweep, wipe sinks, and clean the tubs. Housekeeping staff stated that if residents request something to be cleaned again the staff will do it. They stated that resident rooms and bathrooms are checked daily and cleaned at least once a week. The assistant administrator stated that she hasn't heard of any residents complaining about this issue. A review of the housekeeping duties list reveal that housekeepers are required to mop floors and clean fixtures in the restroom. During the tour of the physical plant on 10/13/21, LPA observed that all resident's bathrooms appeared clean including floors, toilets, showers, and sinks.

Regarding the allegation, "Staff did not change resident's bed linens in a timely manner," interviews with residents revealed: ten (10) out of eleven (11) residents interviewed stated bed linens are changed in a timely manner and that housekeeping changes the sheets several times per week and as needed when they are soiled. One (1) out of eleven (11) residents interviewed stated that bedding Is changed too late in the day. Housekeeping staff interviewed stated that bedding is changed at least 1-2 a week and whenever it is soiled. Bedding is checked daily during housekeeping rounds and are changed more frequently if needed. Staff denied the allegation. During the tour of the physical plant on 10/13/21, LPA observed that all resident's bedding was clean.

Regarding the allegation, “Resident was put on a 72 hour hold without cause” it was alleged that a resident was forced to leave the facility on a psychiatric hold for no legitimate reason. Interviews with the S5-S6 who were involved in the incident indicated that the resident was a danger to himself and others which is why a 72-hour hold was placed. S5 stated that R1 was had been drinking and was being aggressive with staff and residents and refusing to take psychiatric medications. S5 called the psychiatrist who approved the 72-hour hold and the Downey Police Department were called to assist. LPA obtained the police incident report dated 9/14/21 which stated that R1 was upset with roommate and was “non-compliant and being aggressive towards staff.” R2 stated that, during the incident, R1 was arguing and yelling at staff and refusing to take his medications. There were no other resident witnesses involved and all other residents interviewed did not have details about the incident. Other staff interviewed did not have knowledge of the incident. A review of incident report dated 9/15/21 states that R1 was being non-compliant and aggressive towards staff and facility staff called psychiatrist who ordered the 72-hour hold. The psychiatrist was unable to reached by LPA for interview. ***Continued on LIC9099C***


SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 28-AS-20211006120622
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: 12/08/2021
NARRATIVE
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Based on interviews, observations, and records reviewed, it is determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with the assistant administrator Cynthia Flores and copy of report was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
10/06/2021 and conducted by Evaluator LaJean Nicole Spencer
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211006120622

FACILITY NAME:LAKEWOOD PARK MANORFACILITY NUMBER:
198602950
ADMINISTRATOR:LISA PHAMFACILITY TYPE:
740
ADDRESS:12045 LAKEWOOD BLVDTELEPHONE:
(562) 923-4417
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:160CENSUS: 109DATE:
12/08/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cynthia Flores, assistant administratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not safeguard residents personal belongings
Staff did not provide adequate food service
Staff withheld residents mail
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent complaint visit for the allegations listed above. LPA Spencer met with assistant administrator Cynthia Flores and explained the purpose of today's visit.

The investigation consisted of the following: During the initial visit on 10/13/21, LPA conducted a tour of the physical plant including a sample of resident rooms and observed meal service. LPA Spencer interviewed the assistant administrator, staff #1-4 (S1-S4), and residents #1-11 (R1-R11). During the course of the investigation, LPA interviewed staff #5-6 (S5-S6). LPA collected a copy of the staff roster, resident roster, menu, cleaning schedule and housekeeping duties. For R1, LPA collected incident reports, police report, physician's report, and admissions agreement.

***See LIC9099C for continuation of this narrative.***
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: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 28-AS-20211006120622
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: 12/08/2021
NARRATIVE
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The investigation revealed the following: Regarding the allegation, “staff did not safeguard resident’s personal belongings,” interviews with residents revealed: eight (8) out of eleven (11) residents stated that they have items missing or stolen from their room. Three (3) out of eleven (11) residents stated that they have not had anything missing or heard of any other residents with this issue. Residents with missing items stated that when they informed the staff, nothing was done about it. Staff interviewed stated that they have not heard of any residents complain about stolen or missing items. The assistant administrator stated that resident inventory is taken upon admission unless they opt out. She stated all resident rooms are locked unless they leave the door open. A review of the admissions agreement theft and loss policy states that items reported lost or stolen will be replaced or reimbursed. A review of R1’s inventory list reveals that the items allegedly missing were not listed on the form. Staff notes indicated that facility staff packed up resident’s items upon move out but R1 refused to sign the move-out inventory list. During the physical plant tour on 10/13/21, LPA observed that R1’s antennae was found under the bed. The other missing items were not found during the tour.

Regarding the allegation, “staff did not provide adequate food service,” it was alleged that hot meals are served to residents cold/luke warm and service takes too long. Interviews with residents revealed: nine (9) out of eleven (11) residents interviewed stated that meals are served luke warm or cold and the wait times for meals are at least one (1) hour. Two (2) out of eleven (11) residents interviewed stated that the food is served at an adequate temperature and wait times are not too long. Dietary staff interviewed stated that meals are served to residents right away and those who get foods delivered to their room have their food saran-wrapped to keep it warm. The assistant administrator stated that she has had no complaints regarding food service. A review of the menu reveals that residents are served with a variety of foods. LPA Spencer observed meal service during the visit on 10/13/21. LPA observed that residents with tray service had their food plated at 11:37 a.m. and the last resident received their plate at 12:27 p.m. (50 minute wait time). During lunch time in the dining room, LPA observed that residents were seated in the dining room at 12 p.m. and the first table was served their food at 12:45 p.m. (45 minute wait) while the last table was served their food at 1:13 p.m. (73 minute wait time).

***See LIC9099C for continuation of this narrative***

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 28-AS-20211006120622
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: 12/08/2021
NARRATIVE
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Regarding the allegation, “staff withheld residents mail” it was alleged that staff do not provide residents with their mail in a timely manner. All residents interviewed stated that they must inquire about their mail and are not informed when mail comes for them. The assistant administrator stated that mail is sorted by herself or the front desk staff and they put in a file folder. She stated that residents usually call or come down to pick up their mail. LPA observed the file folder located in the front office which had mail still placed in it. In R1’s file, a copy of a UPS letter marked “return to sender” was observed. Assistant administrator stated that residents are not delivered the mail to their rooms but will call to inquire about their mail or come down to get it. Other staff interviewed were not aware of this issue.

Based on observation, interviews, and records reviewed the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Pursuant to Title 22, deficiencies cited on the attached 9099D.



An exit interview was conducted with the assistant administrator and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 28-AS-20211006120622
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited
CCR
87218(a)
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87218(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety code section 1569.153. This requirement was not met as evidenced by...
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The administrator stated that they will ensure that the inventory list is accurate, and once a month, the staff will send notice to residents to update their inventory. Administrator stated that she will send a copy of the letter to CCL by POC due date.
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Based on interviews, the licensee did not ensure that 8 out of 11 residents interviewed had valuables that were adequately safeguarded. This poses a potential risk to the personal rights of persons in care.
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Type B
12/13/2021
Section Cited
CCR
87468.2(a)(5)
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87468.2(a)(5) Residents in RCFE's shall have personal rights which include...to be served food of the quality and quantity necessary to meet their nutritional needs. This requirement was not met as evidenced by...
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The administrator stated they will divide the serving staff so that some are doing tray delivery and others will do in the dining room. The administrator will create a new policy that states that residents will have no longer than a 30 minute wait for meals.
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Based on observation and interview, the licensee did not ensure that residents were served the quality temperature of food in a timely manner. This poses a potential risk to the health of persons in care.
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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: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 28-AS-20211006120622
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited
CCR
87468.1(a)(15)
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87468.1(a)(15) (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by:
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The administrator stated that she will create a self-certified letter that mail will be sorted and residents will be delivered the mail to their room at least once a day on the same day that their mail arrives.
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Based on observation and interview, the licensee did not ensure that all residents were informed about and received their mail in a timely manner. This poses a potential risk to the personal rights of persons in care.
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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: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8