198602950-12-1-2022-28-AS-FFIS-CMB265-20221220160631

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 12/01/2022
Date Signed: 12/01/2022 12:04:10 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
03/09/2020 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200309155306

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: 116	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Cynthia Flores- Executive Assistant		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident is not getting showers.
Resident's bed is broken.
Staff did not safeguard resident's personal items.
Staff are not providing resident alternative meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Executive Assistant Cynthia Flores and explained the purpose for the visit.

On 03/19/2020, LPA B. Tao condutcted a telephonic investigation due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. During the investigation, LPA Tao interviewed Executive Assistant Cynthia Flores and requested copies of residents roster, staff roster, shower slips, picture of the bed showing the location of the bed rail, IPP, dietary menu, face sheet and phyician report, to be faxed to the LPA’s attention at the Regional Office Address listed above by 03/25/2020.

(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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-20200309155306

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: 12/01/2022

NARRATIVE

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During Today's visit, LPA Maldonado obtained a copy of the staff and resident roster, toured the resident's old bedroom (room#5), and conducted interviews with Staff# 2-5 (S2-S5). LPA was unable to interview Resident# 1 (R1) due to R1 no longer residing at the facility.

The investigation revealed the following:

Regarding allegation- Resident is not getting showers.
It is alleged that R1 was receiving one shower every three weeks due to staffing issues. Per R1's physician's report, R1 requires assistance with bathing. (4) of (5) staff stated that any time R1 or any resident refuse a shower, staff would ask the resident and confirm their decision. This would then be logged and signed by the resident and a witness, unless the resident refuses to sign, then it would be signed by the staff and a witness. After review of shower logs for February-March 2020, it was confirmed that R1 did receive frequent baths, however R1 would refuse/change their scheduled days every week. The changes/refused days are reflected on the logs provided.

Regarding allegation- Resident's bed is broken.
It was alleged that when R1 moved into the facility, R1 had a hospital bed that moved up and down; However it stopped working and would not go up anymore. S2 states R1 requested to have the bed rails removed from the bed as it made it difficult for R1 to transfer from wheelchair to bed on their own. LPA received proof of a document signed by R1 acknowledging their request to have the rails removed. All staff interviewed stated they have no knowledge of R1 ever falling off the bed due to the removal of the bed rails. All staff interviewed stated they have no knowledge of R1's bed being broken.

Regarding allegation- Staff did not safeguard resident's personal items.
It is alleged that R1 had missing clothes and that other people go through R1's personal belongings. S2 stated that during R1's stay at the facility, R1 moved from the initial admissions room to another room. During the move, R1 stated a couple of shirts were missing. S2 assisted R1 to look for the shirts R1 claimed to be missing and found them with the rest of R1's clothes. (3) of (5) staff interviewed stated they have no knowledge of R1 reporting they had missing clothes or people were going through R1's personal belongings.

(Report Continued on LIC9099-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200309155306

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: 12/01/2022

NARRATIVE

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Regarding allegation- Staff are not providing resident alternative meals.
It is alleged that due to R1 going to dialysis and returning late, R1 misses meal times and is not provided a meal upon return to the facility. R1 is also diabetic and due to condition, R1 needs to eat. All staff interviewed stated that R1 and all other residents who go to dialysis are always served and saved a plate of food to be given to them upon their return. All staff stated that R1 was always prepared meals based on their special diet, however R1 was non-compliant with the special diet. All staff stated R1 always requested to have the regular meal all other residents were served, if R1 decided to eat at the facility; However, R1 would also return from dialysis with their own meal from outside restaurants or would order delivery to the facility. All staff stated that residents who go to dialysis are served a meal to eat before they leave and are served a sacked lunch, based on their special diet, to take with them and eat while they're out.

Based on LPA's interviews, the investigation revealed: 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 is unsubstantiated.

Exit interview conducted with Executive Assistant Cynthia Flores and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

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