198602950-11-4-2022-28-AS-MVAO-CL8ULA-20221116144026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 11/04/2022
Date Signed: 11/04/2022 03:50:00 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
11/02/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221102115045

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: 111	DATE:	11/04/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Lisa Pham, Administrator		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illegal Eviction.
Administrator retaliated against resident.
Staff did not safeguard resident's personal property.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with Assistant Administrator Cynthia Flores. Administrator Lisa Pham arrived shortly after.

The investigation consisted of: Staff (S1-S8), resident (R1- R12), skilled nursing staff, and ALW program staff were interviewed. An interview was attempted with R1's family A tour of the interior and exterior physical plant was conducted. Resident (R1's) room, laundry rooms, and storage areas were inspected. Resident (R1's) file documents were obtained, as well as the resident and staff rosters.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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-20221102115045

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: 11/04/2022

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: Illegal Eviction. Based on interviews conducted and record review the findings indicate resident (R1) went to the hospital on 9/10/22 and then was discharged on 9/18/2022 to a skilled nursing facility for higher level of care. On 10/12/2022, facility staff (S7) went to the skilled nursing facility to evaluate the resident, take pictures of R1's wounds, and to inform the resident that it needs to pay October 2022 rent in order for the facility to hold the resident's room. The resident paid in full October 2022 rent fees. It is also alleged that the facility called R1's mother and asked her to pick up R1's personal belongings because the resident was being discharged due to higher level of care needs. Resident (R1) is self-responsible, and mother is only listed as a secondary contact in file documents. On 11/1/2022, the resident's mother went to the facility to pick up R1's personal belongings. It is alleged that resident (R1) was not given written notification that it was being discharged from the facility or issued an eviction notice. The resident did not sign any discharge documents and planned to pay for November 2022's rent. However, on 10/28/2022, R1 received a phone call from facility staff (S2) informing the resident that it cannot be accepted back to the facility per MD order that indicated it requires a higher level of care. One (1) resident out of 12 interviewed stated the facility illegally evicts residents. All staff interviewed denied the allegation. Staff stated that on 11/1/2022 the resident called the facility and informed staff that it's mother would be going to the facility the same day to pick up it's personal belongings. Per Physician Order dated 10/27/2022, the resident required higher level of care. Therefore, the resident was not issued an eviction notice, and the resident is still receiving care at the skilled nursing facility. There is insufficient evidence to prove the allegation.

Allegation: Administrator retaliated against resident. It is alleged that facility administration staff discharged the resident without notice, with a pretense that R1 requires higher level of care. Due to the fact that several months ago R1 filed a complaint against facility staff. A total of eight (8) staff were interviewed; of which one (1) staff stated that sometimes staff have retaliatory attitude towards the residents. Five (5) out of 12 residents reported retaliatory actions against residents if and when a resident complains to facility staff or Community Care Licensing. The residents stated that they receive "lousier" service and staff get moody/mad at the residents. Based on interviews conducted, there is insufficient evidence to prove the resident was not accepted back to the facility as a retaliatory action.

See LIC 9099C report continuation

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20221102115045

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: 11/04/2022

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: Staff did not safeguard resident's personal property. According to interviews conducted facility staff called R1's mother to come to the facility to pick up the resident's belongings, and the resident's mother went to the facility and was not allowed to go into the resident's room to pack the belongings, and ensure all personal belongings were picked up. Instead, staff (S2) packed all the resident's belongings. It is alleged that R1's blood pressure monitor, clothes, elevation pedal, 3 colognes, and all personal belongings were not given to R1's mother upon pick-up. The only things that were returned were furniture items like microwave, paintings, and larger furniture pieces. Based on staff interviews, on 10/28/22 facility staff (S2) called the resident at the skilled nursing facility to inform R1 that per MD order the resident requires a higher level of care. The resident was asked if it wanted facility staff to take its personal belongings to the skilled nursing facility, or if it's mother would be picking up the items. Staff (S2) stated that the resident said that it's mother would be picking up the personal belongings. On 11/1/2022 at approximately 11:23 am, resident (R1) called the facility and gave verbal authorization to staff (S2 & S8) that it's mother would be going to the facility on the same day to pick up it's belongings. According to staff, R1's mother had previously visited the facility in September 2022 after the resident was admitted to the skilled nursing facility. R1's mother picked up clothing items, shoes, airpods, and a suitcase containing personal belongings. Per record review, the facility did not fill out an Inventory of Personal Effects form on that date. On 11/1/2022, R1's mother picked up the remaining personal belongings that were left in the resident's room. Facility staff failed to document properly which items were removed, but staff stated one of the items in question, 3 colognes were definitely provided to R1's mother. One (1) out of eight (8) staff stated that sometimes the resident's belongings are not safeguarded, and other residents take personal belongings. One (1) resident stated it's personal belongings are not safeguarded by staff. LPA inspected the R1's room, laundry areas, and storage room and did not observe R1's personal belongings. There is notation from R1's mother indicating 3 personal belongings were missing. However, those personal belongings were not documented on R1's file document Inventory of Personal Effects. There is insufficient evidence to prove the allegation.

Based upon record review and interviews conducted the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted with Administrator Lisa Pham. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3