198602950-12-15-2021-28-AS-MVAO-CB328T-20220126161051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 12/15/2021
Date Signed: 12/15/2021 02:05:24 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
12/09/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211209101633

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:	12/15/2021
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Cynthia Flores, Assistant Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Elevator is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation of elevator is in disrepair. LPA met with Cynthia Flores, the Assistant Adminstrator, and explained the reason for the visit.

During the visit, LPA obtained the Staff and Resident rosters, elevator repair statement. LPA also toured the facility and interviewed the Administrator, Assistant Administrator, 3 Staff, and 10 Residents.

In regards to allegation, elevator is in disrepair. It is determined that a second elevator has been non-operable for several months. The Assistant Administrator stated there are 2 elevators and the second elevator is currently not working. The part has been ordered and waiting for it to arrive. Administrator and Assistant Administrator both indicated they have been following up regularly with the elevator company to achieve repair date. LPA observed 2 elevators side by side on the first floor and a sign indicating "Elevator is out of service" on the elevator to the left. (Continue on LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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-20211209101633

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: 12/15/2021

NARRATIVE

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Interviews with Staff indicated that one of the elevators has been down on and off for a few months. The maintenance staff stated that parts have been ordered in July 2021, but the elevator company has not been able to secure all parts for the repair due to the Coronavirus pandemic; thus delaying the repair. Seven (7) out of ten (10) residents interviewed indicated one of the elevators has not been working and sometimes they have to wait a long time, which causes an inconvenience in reaching their destination. Per Administrator, the resident may utilize the stairs or the ramp in addition to the elevator. Although there is one working elevator for use, there is evidence of the other elevator in disrepair.

Based on LPA observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211209101633

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: 12/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 12/31/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.	1 2 3 4 5 6 7	The licensee shall ensure that elevators are in good repair at all times and will follow up with the elevator service company to obtain time frame for repair. The licensee shall provide LPA a statement with estimated elevator repair date or receipt of completed repair by POC due date 12/31/21. The correction will not be cleared until elevator is repaired.
	8 9 10 11 12 13 14	Based on observation, interviews, and record review, one of the elevators is currently not working which poses a potential health, safety, and personal rights risk to residents in care.	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: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

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