198602950-6-14-2022-28-AS-LHIS-CGXV6M-20220803160946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 06/14/2022
Date Signed: 06/14/2022 03:03:31 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
06/06/2022 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20220606155118

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:	DATE:	06/14/2022
		UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Administrator Lisa Pham		TIME COMPLETED:	03:14 PM

ALLEGATION(S):

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Staff unlawfully evicted a resident while in care.

INVESTIGATION FINDINGS:

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

The investigation consisted of the following: Interviews were conducted with R1 conservator, 5 staff and 3 residents. Resident #1's (R1's) file was reviewed, and facility was toured.

The investigation revealed the following: Allegation: Staff unlawfully evicted a resident while in care.
All 5 staff denied that resident was evicted from facility. 3/3 residents could not collaborate the allegations. R1 tested positive for Covid-19 on May 31 and facility staff instructed R1 to follow Covid prevention protocols by wearing a mask. S3 stated that R1 kept leaving her room without a mask and S3 told her to put on a mask and R1 slapped S3 on her thigh in response on 6/01/22
Continue on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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-20220606155118

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: 06/14/2022

NARRATIVE

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. On same day R1 slapped Administrator on face as she was attempting to assist resident with her face mask. S1 stated that R1 also slapped her on the face on 5/30/22 because staff did not provide cigarettes that she didn’t have yet. All three times police were called. Administrator stated that resident was not happy at facility and R1 called 911 and police arrived and told facility staff that resident had rights and could leave without anyone’s consent. She asked to get her stuff from her room and S1 went with her and when R1 and S1 arrived, R1 threw herself on the floor and stated that she was in a lot of pain and could not get up. R1 called 911 and told them she was in a lot of pain and She was then taken to hospital (Downey PIH). Administrator stated that R1 was not evicted but requires higher level of care and decided to make arrangements to have her admitted next door at Lakewood Park Healthcare. LPA spoke with R1 conservator and she agreed with facility assessment that resident required higher level of care and agreed to have her moved to Lakewood Park Healthcare by the end of today.

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.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC9099 (FAS) - (06/04)

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