198602950-6-22-2021-28-AS-MVAO-C4FP45-20210629105834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 06/18/2021
Date Signed: 06/22/2021 10:56:46 AM

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
04/14/2020 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200414105533

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: 110	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Cynthia Flores (Assistant Administrator)		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff spoke inappropriately to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced site visit to the facility to investigate the above allegation. Upon arrival, LPA met with Cynthia Flores and explained the purpose of the visit.

During the initial investigation on 04/17/20, LPA Rivas conducted telephone interviews with the administrator. Administrator stated she addressed the allegation with the resident but staff involved is on leave of absence. LPA Rivas also requested copies of Staff personnel report, resident roster, actual work schedule for the week of 04/06/20 through 04/12/20 to be emailed to the LPA’s attention.

During today's investigation, LPA Long obtained a copy of the Staff schedule and Resident roster. LPA interviewed Residents #1 to #11 in various locations of the facility between 10:30 am to 11:30 am and interviewed Staff #1 to #10 in various location of the facility between 11:30 am to 12:00 pm. Continue to LIC9099C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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-20200414105533

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: 06/18/2021

NARRATIVE

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In regards to the allegation: Facility staff spoke inappropriately to resident. Interviews with 11 of 11 Residents indicate Staff have not spoken to them inappropriately nor have they seen or heard Staff speak inappropriately to other Residents. Interviews with 10 of 10 Staff indicate they have not spoken to the Residents inappropriately nor have they seen or heard other Staff speak to Residents inappropriately.

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 Cynthia Flores and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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