198602950-11-15-2021-28-AS-LHIS-C9NQSU-20211213112608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 11/15/2021
Date Signed: 11/15/2021 04:37:32 PM

Substantiated

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
11/12/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211112101724

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: 106	DATE:	11/15/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Lisa Pham		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Wrongful Eviction

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Angelica Rea initiated the complaint investigation regarding the allegation listed above. LPA met with Cynthia Flores, the Assistant Administrator, and explained the purpose of the visit.

Regarding the allegation that resident #1 has been wrongfully evicted, the investigation consisted of interview with Administrator, Staff #1, Staff #2, and review of Resident #1's file. LPA obtained the following from resident #1's file: copy of admission agreement dated 7/26/19, resident appraisal dated 12/26/20, physician's report and copies of special incident report(s).

Per interviews with Administrator, and Staff #1- Staff #2, resident #1 attacked resident #2 on 11/6/21. Resident #1 was placed on a 51/50 hold and was admitted to the hospital for evaluation. Per Reporting Party, resident #1 was evaluated on 11/8/21, and the incident was determined to be "situational", and resident #1 needs to follow up with his psychiatrist for possible medication adjustments. According to hospital, resident #1 is able to be discharged and can return to the facility. However per reporting party, the facility is refusing to allow resident #1 to return.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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-20211112101724

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: 11/15/2021

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

Administrator, and Staff #1- Staff #2 stated that resident #1 has not been issued an eviction notice by the facility. Administrator and Staff #1 - Staff #2 stated that they are not allowing resident #1 to return to the facility based on the incident that occurred on 11/6/21. Administrator, and Staff #1- Staff #2, resident #1's primary care doctor, and psych doctor stated that resident #1 needs a higher level of care and can not return to the facility.

Based on document review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22, Division 6.

An exit interview was conducted with Administrator Lisa Pham. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211112101724

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 11/16/2021 Section Cited CCR 87224	1 2 3 4 5 6 7	Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility.	1 2 3 4 5 6 7	Administrator shall abide by Title 22 regulation, 87224 Eviction Procedures. Administrator stated that she will request a 3 day eviction for resident #1.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by: Administrator, and staff #1-staff #2 stated that resident #1 has not been issued an eviction notice. Administrator, and Staff #1- Staff #2 stated that the facility is not allowing resident #1 to return to the facility, even though he is ready to be discharged from the hospital.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3