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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602950
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:23:22 PM


Document Has Been Signed on 02/04/2022 03:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MANORFACILITY NUMBER:
198602950
ADMINISTRATOR:LISA PHAMFACILITY TYPE:
740
ADDRESS:12045 LAKEWOOD BLVDTELEPHONE:
(562) 923-4417
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:160CENSUS: 107DATE:
02/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Cynthia Flores, Assistant AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted a Case Management -Deficiencies visit due to observation made while investigating complaint control #: 28-AS-20220128150605 visit. The purpose of the visit was explained to Assistant Administrator Cynthia Flores.

On 1/26/2022, resident (R1) sustained a fall that resulted in a knee fracture. The facility failed to report the incident within reporting requirements time frame. In addition, during the course of the complaint investigation LPA requested a copy of the incident report. The incident report obtained had incorrect date and was missing time of incident. NOTE: The facility has not faxed any incident reports since November 16, 2021.



Ms. Flores presented LPA a copy of a FAX Transmission Verification Report with time stamp 1/31/2022. However, the fax # the incident reports were sent to was incorrect. Ms. Flores acknowledged the fax # on the Transmission report is incorrect. LPA provided Ms. Flores the correct fax number.

Per Title 22, Division 6, Chapter 8, Article 04. Operating Requirements 87211(a)(1) "A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...."

Deficiency is cited. See LIC 809D.

Exit interview conducted with Assistant Administrator Cynthia Flores. A copy of the report and Appeal Rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2022 03:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/15/2022
Section Cited

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Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee shall submit a written statement that states how this deficiency was corrected. FAX all incident reports that were faxed the wrong number.

In addition, submit proof of staff training and attach the training materials.
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Based on observation during record review for complaint #: 28-AS-20220128150605; resident (R1) sustained a fall on 1/26/22 that resulted in a knee fracture. The incident report was not faxed to Community Care Licensing (CCL). The last incident report received at CCL was 11/16/21. This poses a potential health and safety risk to residents in care.
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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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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