198602950-5-18-2023-28-AS-LHIS-CSBN3Q-20230530100642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:32:59 PM

Unsubstantiated

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
05/09/2023 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230509152710

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: 109	DATE:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Lisa Pham		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Due to lack of supervision, resident had multiple falls
Staff did not inform authorized representative of incidents
Staff do not change resident timely
Resident is double diapered due to staff neglect
Due to staff negligence, resident was left on the toilet for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Administrator, Lisa Pham, and explained the reason for today's visit.

The investigation consisted of: review of resident #1's file, and obtaining copies of specific documents. LPA also interviewed Resident #1 - Resident #12, and Administrator, Staff #1 - Staff #4.

Regarding the allegation that resident #1 had multiple falls due to lack of supervision. Staff interviewed denied the allegation. They stated that resident #1 has not had any falls to their knowledge. Residents interviewed were unable to corroborate the allegation. 10 out of 11 residents stated that staff provide adequate supervision, and have provided assistance to them when they have had falls. Resident #1 stated that he has fallen while at the facility, but was unable to provide details and/or dates of alleged falls.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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 3

Control Number 28-AS-20230509152710

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: 05/18/2023

NARRATIVE

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Regarding the allegation that staff did not inform authorized representative of incidents, Staff interviewed denied the allegation. They stated that staff do inform authorized representatives of incidents. Residents interviewed were unable to corroborate the allegation. 10 out of 11 residents interviewed, stated that their authorized representatives are notified of incidents, or indicated that they did not have an authorized representative.

Regarding the allegation that staff do not change resident timely, Staff interviewed denied the allegation. They stated that residents who receive assistance with toileting, are provided with assistance as soon as they request it. Staff indicated that residents call staff, by using the call light in their room. Staff stated that the call light notification is received by the front desk, and the front desk notifies staff by paging them. The front desk lets staff know which resident(s) need assistance. Residents interviewed were unable to corroborate the allegation. 10 out of 11 residents indicated that they are assisted by staff in a timely manner.

Regarding the allegation that resident #1 is double diapered due to staff neglect, staff interviewed stated that resident #1 requests to be double diapered. Staff interviewed indicated that resident #1 leaves the facility, on his own, and wants to be double diapered since he is often gone for extended periods of time. Residents interviewed were unable to corroborate the allegation. 8 out of 11 residents interviewed, stated that they are not double diapered. 2 out of 11 residents stated that they are double diapered at night, but they don't have a problem with it.

Regarding the allegation that due to staff negligence, resident was left on the toilet for an extended period of time, staff interviewed denied the allegation. Staff interviewed stated that residents are not left on the toilet for a long period of time. Staff stated that they assist residents in transferring to the toilet, and they wait if the resident wants them to wait, or they leave and come back within 5 minutes. Residents interviewed were unable to corroborate the allegation. 10 out of 11 residents stated that they have never been left on the toilet for an extended period of time.

Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230509152710

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: 05/18/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Lisa Pham.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC9099 (FAS) - (06/04)

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