198602950-3-2-2023-28-AS-TVAO-CQCN2Y-20230328100528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 03/02/2023
Date Signed: 03/02/2023 03:57:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/09/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211109130625

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: 117	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	03:35 PM
MET WITH:	Lisa Pham, Administrator		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Neglect resulted in resident being physically assaulted by another resident, causing significant injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cynthia Chan and Tena Herrera conducted a subsequent visit to deliver the finding for the allegation listed above. LPA met with Administrator, Lisa Pham, and Assistant Administrator, Cynthia Flores, to explain the purpose of the visit.

On 11/10/21, LPA Chan conducted the initial complaint visit with a health and safety check. LPA toured the facility, inspected random rooms, tested the hot water temperature, and reviewed food supplies. LPA did not observe any health and safety issues during the visit. LPA obtained the staff roster, resident roster, and documents pertaining to Resident #1 and #2. On 2/2/23, LPA conducted another visit to interview Staff and Residents. The allegation was further investigated by the Department of Social Services Investigations Branch (IB) Investigator Dennis Douglas.

(Continue on LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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-20211109130625

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LAKEWOOD PARK MANOR	FACILITY NUMBER: 198602950
	VISIT DATE: 03/02/2023

NARRATIVE

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The investigation revealed the following:

Allegation - Neglect resulted in resident being physically assaulted by another resident causing significant injuries.

IB investigator D. Douglas conducted interviews with the facility staff, doctors, and victim. During the investigation, it was revealed the Resident #1 (R-1) was not medication compliant prior to an initial incident that occurred on 10/1/21, which R-1 became agitated and was verbally abusive towards staff and other residents. R-1’s psychiatric doctor was notified and requested to send R-1 to the hospital for a psychiatric evaluation. R-1 was cleared to return to the facility after agreeing to comply with taking the psych medication. Upon returning from the hospital, R-1 was placed in another room with a roommate. Another incident took place on 11/6/21 in which R-1 physically assaulted the roommate (R-2). R-2 sustained injuries/lacerations to the hands and head. According to documentation gathered, R-1 was not compliant with medications after returning from the first incident. Staff indicated they tried to encourage R-1 to take the routine medications but could not force R-1 to take them. Some of the staff acknowledged the incidents and that R-1 was inconsistent with taking medication but stated that R-1 had not been physically or verbally abusive prior to the incidents. The Medication Administration Records (MAR) log showed that R-1 was inconsistently taking the psychosis medications from October 2022 – November 2022. Although the psychiatrist and primary physician were notified, the facility did not develop other plans to address R-1’s failure to comply with medications. There were no notes or updated needs and services plan provided to show that additional actions were taken after the first incident of aggressive behavior and the medication non-compliance. Therefore, the allegation of neglect resulting in physical assault of another client is substantiated.

Based on 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. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM***

An exit interview was held. A copy of this report, LIC9099D, LIC421IM, and appeal rights were given to Administrator Lisa Pham.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211109130625

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 03/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 03/03/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit plan to ensure that any resident non-compliant with medication is addressed immediately to prevent any triggers of aggressive behaviors. The POC is due by 3/3/23.
	8 9 10 11 12 13 14	Based on interviews and documents review, licensee failed to provide additional support for R-1 who failed to comply with medication which posed an immediate 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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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