198602950-9-13-2022-28-AS-MVAO-CJNTB8-20220927143443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:45:25 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
12/14/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211214111934

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: 112	DATE:	09/13/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Asst. Administrator, Cynthia Flores		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff stole resident's money.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2: Cynthis Flores); as Administrator (A1: Lisa Pham) was unavailable at the time of this visit. LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff members have symptoms.

The purpose of today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation. Initial 10-Day visit was conducted by LPA Nicol Wesley on 12/23/21. LPA/RA Ceniceros interviewed (between 8:30 a.m. - 9:15 a.m.) one (1) staff and one (1) former staff. Resident #1 was not interviewed as the resident moved out on 03/05/20; and, LPA Nicol Wesley conducted pre-investigation. LPA/RA reviewed (between 9:00 a.m. – 9:45 a.m.) pertinent documents: Admissions Agreement (dated 08/09/18), Emergency I.D. and Information (dated 08/09/18), Physician’s Report (dated 01/07/19),

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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-20211214111934

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: 09/13/2022

NARRATIVE

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Pre-placement Appraisal (dated 08/09/18), Resident Appraisal (dated 11/22/19), Personal Rights (08/09/18),P & I Ledger/Trust Fund Account (dated 01/05/20 - 04/07/20), reimbursement Check #002926 to sister facility (Le Bleu Chateau) dated 04/16/20 for Resident #1's relocation; SSA Letter (dated 05/13/20) addressed to facility regarding Resident #1's stopped payments; current Facility Staff and Residents rosters.

Regarding Allegation #1: this investigation revealed that Resident #1 moved out of the facility on 03/05/20. Administrator (A3: Adam Zenou) was the former administrator at the facility and did not handle Resident #1's P & I monies. The facility contracts with a Resident Fund Management Service company who rendered services for Resident #1's trust fund account. A review of Resident #1's P & I Ledger and payment history from the trust fund account was opened on 01/06/20 and closed on 04/07/20. A direct deposit entry was made on 03/03/20 by SSA Treasury funds in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00); and, an automatic withdrawal (for care cost) in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00) - showed a resident cash advance in the amount of One-hundred Thirty-seven Dollars and No Cents ($137.00) - leaving a zero ($0) balance. On 04/01/20, a direct deposit was made by SSI Treasury funds in the amount of Five-hundred Sixty Four Dollars and Thirty-seven Cents ($564.37); and, an automatic withdrawal (for care cost) in the amount of Four- hundred Twenty-seven Dollars and Thirty-seven Cents ($427.37) - leaving a balance of One-hundred and Thirty-seven Dollars and no Cents ($137.00). On 04/03/20, a direct deposit entry was made by SSA Treasury funds in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00); and, an automatic withdrawal (for care cost) in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00); and, a charge of One-hundred Thirty-seven Dollars and No Cents ($137.00) was charged on 04/07/20 to close account - showed a zero ($0) balance to Resident #1's account. Last direct deposit entry was made on 05/01/20 by SSA Treasury funds in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00) were rejected because there was no account for this direct deposit. On 05/28/20 IRS Treasury funds in the amount of Twelve-hundred Dollars and No Cents ($1,200.00) were also rejected because there was no account for this direct deposit. Interviews conducted corroborated that a follow-up letter addressed to the facility (dated 05/13/20) from Social Security Administration documented payments stopped for Resident #1 due to no correct address, effective 05/01/20. Facility staff issued reimbursement Check #002926 to sister facility (Le Bleu Chateau) dated 04/16/20 in the amount of One-thousand Eighty-nine Dollars and Thirty-seven Cents ($1,089.37) for Resident #1's relocation to their sister facility; therefore, Resident #1's P & I Ledger/Trust Fund Account showed a zero ($0) balance.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211214111934

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: 09/13/2022

NARRATIVE

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Based on the evidence gathered and interview(s) conducted and records reviewed, although the allegationmay have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Staff stole resident's money is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to the Asst. Administrator (Cynthia Flores).

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC9099 (FAS) - (06/04)

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