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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 05/17/2022
Date Signed: 05/17/2022 06:37:27 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
05/09/2022 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220509114229
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: 105DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cynthia Flores, Assistant AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Facility has not provided resident their requested copy of contract.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted the complaint investigation for the allegation listed above. LPA met with Assistant Administrator, Cynthia Flores and explained the purpose of the visit. Administrator, Lisa Pham, arrived shortly thereafter.

The investigation consisted of the following:
LPA obtained a copy of the staff and resident roster, food menu for the month, and reviewed medications for 9 residents. LPA also toured the facility, interviewed the Administrator, 6 Staff, and a total of 11 Residents.

The investigation revealed the following:
Regarding - Facility has not provided resident their requested copy of contract. It is alleged that Resident #1 has been requesting for a copy of the Admission Agreement but has not been provided with one. Administrator Pham stated a resident signs the Admission Agreement upon admission and a copy of the agreement is offered to them. She stated a copy is given to residents even though some may not want it.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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 5
Control Number 28-AS-20220509114229
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: 05/17/2022
NARRATIVE
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LPA interviewed a total of 11 residents. 6 out of the 11 residents stated they did not receive a copy of the Admission Agreement when they moved in, or they were not asked if they wanted a copy, or that a copy was given when requested. According to Title 22 regulation 87507(e), The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.

Based on interviews conducted, 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 exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/09/2022 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220509114229

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: 105DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cynthia Flores, Assistant AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Medication not being provided as prescribed.
Facility toilets are clogged.
Facility not providing adequate food service to resident.
Elevator floor numbers do not light up.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted the complaint investigation for the allegations listed above. LPA met with Assistant Administrator, Cynthia Flores and explained the purpose of the visit. Administrator, Lisa Pham, arrived shortly thereafter.

The investigation consisted of the following:
LPA obtained a copy of the staff and resident roster, food menu for the month, and reviewed medications for 9 residents. LPA also toured the facility, interviewed the Administrator, 6 Staff, and a total of 11 residents.

The investigation revealed the following:
Regarding - Medication not being provided as prescribed. Administrator and Staff interviewed stated that residents are being administered the medication as prescribed. They do not have any residents non-compliant with medications.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220509114229
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: 05/17/2022
NARRATIVE
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The Med Techs pass out medication starting as early as 6am (morning time), 12pm (afternoon), 4pm (evening), and 7pm (bedtime). The Med Techs will go to the residents' rooms or pass out the medications during the meal time in the dining room. For residents with PRN, they will need to request from the med tech. 10 out of 11 residents interviewed stated that they take medications daily and on time. LPA also reviewed medications for 9 Residents and compared the medications to the MAR log. It is determined the routine medications are being administered as prescribed.

Regarding allegation - Facility toilets are clogged. The administrator stated that the toilets sometimes get clogged due to residents throwing in baby wipes, however, they will get it fix right away. The maintenance staff stated that the toilets get clogged at times, but he or the housekeepers, will get it unclogged the same day. 10 out of 11 stated either there are no issues with the toilet or the toilet gets clogged but the staff will get it unclogged once they are notified. LPA toured the facility and observed toilets working properly.

Regarding allegation - Facility not providing adequate food service to resident. It is alleged that the food are served cold. During the visit today, LPA toured the dining room and kitchen area during lunch time. LPA observed the kitchen staff preparing the plates to serve the residents. The foods were kept in a steamer to keep the food hot. The plates being delivered to the residents in the rooms were wrapped. Staff interviewed did not hear of any residents complaining their foods are served cold. 10 Residents interviewed stated that the food are served hot or warm but not cold.

Regarding allegation - Elevator floor numbers do not light up. During the tour of the facility, LPA tested the elevators buttons which were working properly. The staff stated there are no issues with the elevators recently. 10 out of 11 Residents interviewed stated that the elevator buttons light up when they press them.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with the Administrator. A copy of this report along with the appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220509114229
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: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/24/2022
Section Cited
CCR
87507(e)
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87507 Admission Agreement (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification...
This requirement is not met as evidenced by:
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The Administrator shall review regulation 87507 Admission Agreement and provide a copy of the Admission Agreement to all residents and representative. The Administrator shall submit a statement acknowledging this regulation by POC due date 5/24/22.
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Based on interviews, 6 out of 11 residents did not obtain a copy of the Admission Agreement upon signing the agreement or provided another copy when requested which poses a potential personal rights 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: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5