<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:03:01 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
12/01/2022 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221201150942
FACILITY NAME:LAKEWOOD PARK MANORFACILITY NUMBER:
198602950
ADMINISTRATOR:LISA PHAMFACILITY TYPE:
740
ADDRESS:12045 LAKEWOOD BLVDTELEPHONE:
(562) 923-4417
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:160CENSUS: 115DATE:
12/06/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cynthia Flores- Executive AssistantTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not feed resident.
Staff did not seek timely medical care for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit to 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.

During today's visit, LPA obtained a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, physician's report, Needs and Services Plan, Notice of Hospice Initiation, Hospice Care Plan, Physician's Orders for Life-Sustaining Treatment (POLST), Hospice Records/Notes, and hospital dishcarge documents. LPA also conducted interviews with Staff# 1-2 (S1-S2), the hospice case manager (CM), and hospice nurse (HN).

The investigation revealed the following:

(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
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 2
Control Number 28-AS-20221201150942
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: 12/06/2022
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
Regarding allegation- Staff did not feed resident.
It is alleged that facility staff did not feed R1 causing R1 to go into an altered state of consciousness. Per Hospice Initiation notice, it was discovered that R1 was admitted to hospice care on 11/20/22. S2 stated that hospice was notified on 11/21/22 that R1 was noted to not be eating well. Prior to being placed on hospice care, R1 was eating about 70% of meals. CM confirmed the information, stating that the facility also requested an order for pureed food for R1 to encourage R1 to eat. S2 stated that on 11/30/22, R1 was noted to have difficulty swallowing and did not eat breakfast or lunch after several attempts to assist with eating- hospice was notified. On 11/30/22, HN arrived at the facility and confirmed the reports of R1 not eating well due to difficulty swallowing, after completing an assessment. This allegation is unsubstantiated.

Regarding allegation- Staff did not seek timely medical care for resident.
It is alleged that on 12/01/22 at about 1:00PM, R1's family asked the facility to call 911 to transfer the resident to the emergency room. Per interviews conducted, 4 of 4 individuals interviewed stated on 11/30/22, hospice and R1's family member (FM) were notified of R1's health declining. Per R1's POLST, R1 was Do Not Resuscitate (DNR), which would indicate that hospice would keep R1 comfortable until expiration, in case of changes in condition. CM stated HN was sent to facility at 9:1PM for continuous care of R1. Per interviews with S2 and CM, after R1's FM was notified of changes, FM requested R1 be placed at another facility or hospital due to R1's health decline. CM coordinated a telephone call with FM and S2 to discuss requested changes. CM advised against moving R1 due to possibility of R1 expiring en route and FM not being able to visit prior to expiration. CM and S2 stated FM requested R1's POLST to be changed from DNR to Full Code, which would indicate that R1 would now receive all medical measures to try and keep R1 from expiring. At 12:38PM, HM coordinated with S2 and HN to call 911, per change in POLST. Paramedics arrived shortly after and took R1 to the hospital. Per hospital records, on 12/01/22, R1 was admitted and expired at the hospital. CM states that facility notified hospice promptly and followed all protocols for patients on hospice care. 911 was not called immediately due to initial POLST signed as DNR. This allegation is unsubstantiated.

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.

An exit interview was conducted with executive assistant Cynthia Flores and copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2