198602950-9-23-2022-28-AS-RORN-CJNL7L-20220927083028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 09/13/2022
Date Signed: 09/23/2022 02:43:59 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
01/05/2022 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220105161023

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:	10:30 AM
MET WITH:	Asst. Administrator, Cynthia Flores		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident was illegally evicted.
Licensee violated the terms of the admission agreement regarding refunds.
Staff did not provide an inventory of resident's personal items upon request.

INVESTIGATION FINDINGS:

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***AMENDED REPORT***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 allegations. An initial 10-Day visit was conducted by LPA Nina Galarza on 01/14/22. LPA/RA Ceniceros interviewed (between 10:30 a.m. - 11:30 a.m.) three (3) staff members; however, Resident #1 was not interviewed as the resident moved out of the facility on 12/28/21; however, LPA Nina Galarza conducted the pre-investigation. LPA/RA Ceniceros reviewed (between 12:30 p.m. – 1:30 p.m.) pertinent documents: Admissions Agreement (dated 12/22/21), Emergency I.D. and Information (dated 12/22/21), Safeguard for Property Valuables (dated 12/22/21), Acknowledgement of Discharge (signed 12/28/21), and

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)

Page: 1 of 3

Control Number 28-AS-20220105161023

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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Inventory of Residents Personal Property (signed 01/03/22) for Resident #1; and Staff & Residents rosters.

Regarding Allegation #1: this investigation revealed that Resident #1 is own responsible person. Resident #1 shows a daughter as a secondary contact person based upon the resident's Emergency I.D. & Information Face Sheet (dated 12/22/21). On 12/28/21, the only incident that occurred was that Resident #1 signed an "Acknowledgement of Discharge" vacating the facility and removed all personal belongings without providing a 30-Day advance notice of intent to move or vacate the premises. When hospital staff contacted the facility on 12/29/21 and spoke to Staff #1 (S1: Olga Morales, Med Tech - A.M.) to advise that Resident #1 was being discharged from the hospital, Staff #1 advised hospital staff that the resident no longer resided at the facility; as Resident #1 discharged from the facility on 12/28/21. A review of Resident #1's "Admission Agreement" (signed on 12/22/21) documented, "The facility will refund the pre-admission fee under the following circumstances: (1) if the applicant decides not to enter the facility (prior to the facility's completion of a pre-admission appraisal)"; of which, a "Pre-placement Appraisal" was completed on 12/22/21 and "Physician's Report" completed on 12/15/21. This one time Pre-admission Fee in the amount of Five-hundred Dollars ($500) covers: resident appraisal, room preparation, arrange and/or review physician's assessment, cost of admission forms and materials, staff time, inventory of personal belongings, employee training, dietary provisions, medication set up, and other admission-related expenses. This Five-hundred ($500) fee is collected - prior to admission and prior to the required facility assessment; of which, the latter two (2) had been completed on 12/15/21 and 12/22/21. Interviews conducted corroborated that Resident #1 signed an "Acknowledgement of Discharge" and vacated the facility and removed all personal belongings on 12/28/21 without providing a 30-Day advance notice of intent to move or vacate the premises.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may 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 EVICTION/DISCHARGE: Resident was illegally evicted is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that a review of Resident #1's "Admission Agreement" (signed on 12/22/21) documented: "The facility will refund the pre-admission fee under the following circumstances: (1) if the applicant decides not to enter the facility (prior to the facility's completion of a pre-admission appraisal)"; of which, a "Pre-placement Appraisal" was completed on 12/22/21. This one time

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-20220105161023

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-admission fee in the amount of Five-hundred Dollars ($500) covers: resident appraisal, room preparation, arrange and/or review physician's assessment (cost incurred by resident), cost of admission forms and materials, staff time, inventory of personal belongings, employee training, dietary provisions, medication set up, and other admission-related expenses. This fee is collected - prior to admission and prior to the required facility assessment; of which, the latter two (2) had been done on 12/15/21 and 12/22/21. LPA/RA Ceniceros re-interviewed reporting party/family member who indicated that facility should have reimbursed some monies from the $2,300 rent and $500 pre-admission fee during Resident #1's seven (7) day stay at the facility (from 12/22/21 thru 12/28/21. Interviews conducted corroborated that Resident #1 failed to give the facility a 30-Day Notice to Move as agreed upon per "Admission Agreement" (signed on 12/22/21); rather, Resident #1 signed an "Acknowledgement of Discharge" on 12/28/21 and vacated the facility and removed all personal belongings.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may 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 ADMISSION AGREEMENT: Licensee violated the terms of the admission agreement regarding refunds is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed interviews conducted corroborated that Resident #1 had "removed all personal belongings from Room #3", signed and dated on 12/28/21. LPA/RA Ceniceros reviewed Resident #1's records which documented the resident's "Safeguard for Property Valuables" (dated 12/22/21) and "Acknowledgement of Discharge" (dated 12/28/21) were both signed by Resident #1. LPA/RA Ceniceros observed the "Inventory of Residents Personal Property" and "Certification of Receipt" signed and dated by Resident #1's relative on 01/03/22 and witnessed by Assistant Administrator (Cynthia Flores).

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may 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 did not provide an inventory of resident's personal items upon request is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to 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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