198602950-6-13-2022-28-AS-WSHO-CGWSE4-20220802134805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 06/13/2022
Date Signed: 06/13/2022 01:18:34 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
06/08/2022 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220608110027

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: 109	DATE:	06/13/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Cynthia Flores, Assistant Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not communicating with resident's responsible party.
Facility did not seek resident timely medical attention.
Electrical wires unsafe in resident's room.
Facility failed to safeguard resident's belongings.
Resident touched inappropriately by another resident.
Residents are not treated with dignity or respect.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Cynthia Flores and explained the reason for the visit. Administrator, Lisa Pham was called and notified of the allegations.

The investigation consisted of the following: Interviews were conducted with 4 staff and 3 residents. Resident #1's (R1's) file was reviewed and facility was toured.

The investigation revealed the following: Allegation: Facility is not communicating with resident's responsible party. Staff interviewed were well informed on R1's needs and medical appointments. Staff indicated they are in regular contact with R1's family and keep them updated through phone calls and text messages. R1 was interviewed and could not confirm if the allegation was true. There was no evidence to prove this allegation occurred. This allegation is unsubstantiated.
Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

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 3

Control Number 28-AS-20220608110027

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: 06/13/2022

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

Allegation: Facility did not seek resident timely medical attention. Allegedly R1 has missed several medical appointments due to facility staff. Staff interviewed included management and caregiver. Staff indicated the reason some medical appointments are missed is because R1 or R1's family wants them cancelled. The medical appointment calendar was reviewed. R1 went to appointments on 3/17/22, 4/25/22, and 6/7/22. Facility incident reports from January 2022 indicate medical appointments were rescheduled 4 times because R1 had family plans. R1 was interviewed and did not confirm any medical appointments were missed, but were rescheduled. R1 indicated he/she recently saw a doctor. There was no other evidence that medical appointments have been missed. This allegation is unsubstantiated.

Allegation: Electrical wires unsafe in resident's room. Allegedly there are exposed wires in R1's room. R1's room was toured. There were no exposed electrical wires observed. R1's previous room was also toured. That room also did not have any exposed electrical wires. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Facility failed to safeguard resident's belongings. Allegedly R1's electric wheelchair was broken at the facility. Staff interviewed stated that the seat on R1's electric wheelchair was torn when R1 was out in the community. Staff indicated electric wheelchairs are not allowed inside the facility. The facility repaired the seat even though they feel it was not damaged at the facility. R1 indicated the electric wheelchair is working fine and indicated it was scratched out in the community. R1 said the electric wheelchair is only used out in the community and has a manual wheelchair inside the facility. Other residents reported seeing R1 in the electric wheelchair and didn't know if it was ever damaged. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Resident touched inappropriately by another resident. Allegedly R1 was touched and kissed by a male resident at the facility. Staff reported sometime last year R1 reported that a male friend walked into his/her room and attempted to kiss him/her. Staff spoke with the male resident and called the police. Incident report dated 7/25/21 documents what was reported by R1 and indicates Downey Police Department arrived to interview both parties. Families were notified of the incident. The male resident moved out a short time later. Other facility residents were interviewed. They did not have any information about the alleged incident. There is insufficient evidence to prove the alleged incident occurred. Therefore, the allegation is unsubstantiated.

Continued on 9099C.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220608110027

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: 06/13/2022

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

Allegation: Residents are not treated with dignity or respect. Allegedly facility staff accused R1 of stealing from the store and made a scene in front of other residents. Staff confirmed there were some incidents with R1 brining in clothing from the stores nearby without bags, but never accused R1 of stealing. An incident report dated 11/2/21 documents that on 11/2/21, a man from a nearby store entered the facility and reported that R1 was seen putting items in his/her electric wheelchair and leaving the store without paying. The man indicated he would be calling the police. R1 was asked to provide receipts for the purchases, but R1 could not provide the receipts. Later that day police arrived to interview R1, but R1 was asleep. R1 was interviewed today and denied stealing anything. R1 did confirm that he/she was interviewed by someone about stolen items from a store. Residents interviewed reported never witnessing staff accusing R1 of anything. There were no other witnesses to the alleged incident. Based on the information obtained, the allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview held. A copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3