198602950-5-28-2021-28-AS-CYEE-C4EV7T-20210628161141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 05/28/2021
Date Signed: 05/28/2021 02:51:26 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
05/25/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210525105528

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: 110	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cynthia Flores		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff refused to provide resident's medical records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Spencer conducted an initial investigation for the allegation listed above. LPA Spencer met with assistant administrator Cynthia Flores and explained the purpose of today's visit.

During the investigation, LPA Spencer took a tour of the physical plant, interviewed assistant administrator Cynthia Flores and residents #1-10 (R1-R10), and requested a copy of the staff and resident roster. LPA reviewed resident records for 3 specified residents containing documents including face sheet, physician's report, appraisal/pre-appraisal, needs & services plan, and medical cards.

The investigation revealed the following: During interviews, assistant administrator Cynthia Flores stated that resident records are kept at the facility three (3) years after moving out and are available upon request. She stated that she hasn't had anyone request medical records recently but will provide them to residents if requested. A review of the resident records revealed that R1's medical records were retained at the facility.
***See LIC9099C for continuation.

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: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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-20210525105528

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: 05/28/2021

NARRATIVE

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R1 stated that she recently requested medical records but was told that there were no records at the facility. R2-R10 stated that they have not had any trouble receiving their medical records and have not heard of any other residents having trouble receiving their medical records.

Based on interviews and records reviewed, there was no indication that staff refuse to provide medical records. Although the allegation 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 allegation is Unsubstantiated.

A telephonic exit interview was conducted with the assistant administrator Cynthia Flores and copy of 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: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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