198602950-4-26-2023-28-AS-TVAO-CSBPM7-20230530112549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 04/26/2023
Date Signed: 04/26/2023 01:23:35 PM

Unsubstantiated

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
02/04/2021 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210204111702

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: 108	DATE:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Staff 1		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Unexplained death.
Facility restrained resident.
Facility did not get medical assistance for resident in a timely manor.
Staff did not respond timely to resident pull cord due to insufficient staffing.
Staff did not change residents soiled diaper timely due to lack insufficient staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit to deliver findings on 04/26/2023, stemming from subsequent complaint visit dated 04/25/2023, conducted by LPA Ramirez and initial 10-day complaint visit conducted on 02/05/2021, by LPA Wesley. LPA was met by Staff 1 (S1) and explained the purpose of the visit.

Allegations:
• Unexplained death- It is alleged on or around January 10, 2021, Resident 1 (R1) was transported via 911 to local hospital and unexpectedly passed away four days later at local hospital. Four (4) out of four (4) staff deny having knowledge of this allegation. LPA could not confirm that R1 passed away four days later at local hospital. LPA was unable to obtain death certificate/death report. LPA was unable to contact R1’s surviving sibling due to sibling phone number being out of service. LPA was able to confirm R1's personal belongings were picked and R1 was discharged on 01/12/2021 from facility by R1's sister. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. There was no evidence, or witness statements provided at time of visit to support this allegation.

SEE LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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-20210204111702

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: 04/26/2023

NARRATIVE

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·Facility restrained resident- It is alleged that on or around January 09, 2021, unknown staff restrained R1, by tying R1 to the bed, as to prevent R1 from throwing self onto floor. Four (4) out of four (4) staff deny having knowledge of this allegation. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. LPA toured two (2) resident accommodations at random (room 19 & 52 ), LPA did not observe restraints of any kind near bed frame or head board. LPA did not observe any hazards during tour of facility. There was no evidence, or witness statements provided at time of visit to support this allegation.

· Facility did not get medical assistance for resident in a timely manner- It is alleged on or around January 10, 2021, R1 was suffering from a medical emergency and staff prolonged calling 911. Four (4) out of four (4) staff deny having knowledge of this allegation. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. On April 25, 2023, at 6:32 pm, LPA Ramirez contacted the Downey Police Department at 562-861-0771. LPA confirmed no service calls were made on or around January 10, 2021, to 911 requesting service at 12045 Lakewood Blvd, Downey 90242. LPA could not confirm if a private ambulance service was dispatched to facility address. LPA could not locate any SIR’s in department database however, staff provided LPA with copy of SIR dated 01/10/21, describing incident regarding R1. Facility acknowledged R1 was not at the facility between 01/11/21 through 01/12/21. Facility staff acknowledges R1 was transferred to local hosiptal. LPA was able to obtain a copy of in-house Training Sign in Sheet for staff receiving training on Emergency (911) and non-emergency calls, recognizing change of condition, and other various training's dated May 16, 2018 through March 07, 2023. There was no evidence, or witness statements provided at time of visit to support this allegation.

· Staff did not respond timely to resident pull cord due to insufficient staffing- It is alleged on or around December 31, 2021, through January 10, 2021, staff did not respond to pull cord in a timely manner when R1 needed assistance. Four (4) out of four (4) staff deny having knowledge of this allegation. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. LPA toured random resident room 19 and tested pull cord at 12:46 pm. Staff responded to resident room 19 at 12:47 pm to assist. LPA obtained a copy of Recap Medication & other duties in-house training sign in sheet dated June 23, 2022. According to staff, when a resident pulls the emergency cord in their room, the facility signaling system will light up and make a noise to alert which room is needing assistance. Staff will assist within 5 minutes. Four (4) out of the four (4) residents interviewed confirm staff arrive no more than 5 minutes after calling for assistance. There was no evidence, or witness statements provided at time of visit to support this allegation.

SEE LIC 9099-C for continuation

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210204111702

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: 04/26/2023

NARRATIVE

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·Staff did not change residents soiled diaper timely due to lack insufficient staffing- It is alleged on or around December 31, 2021, through January 10, 2021, R1 was left soiled for two hours. Four (4) out of four (4) staff deny having knowledge of this allegation. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. According to three (3) out of the four (4) staff interviewed, staff check on incontinence residents at a minimum of every two hours. If a resident request to be changed sooner, staff will assist in changing resident upon request. There was no evidence, or witness statements provided at time of visit to support this allegation.

Based on record review and interviews conducted the findings indicate, although the allegation(s) may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

Exit interview was held with Staff 1 (S1) and a copy of this report was emailed due to printer issues.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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