198602950-6-1-2023-28-AS-RORN-CSZLK2-20230621084850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:42:57 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
05/23/2023 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230523094907

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: 103	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Cynthia Flores (Assistant Administrator)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff refusing to provide resident with medical/physician contact information.
Staff not assisting resident with showers.
Residents bed is in poor condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegations. LPA met with Cynthia Flores (Assistant Administrator) and discussed the purpose of today’s visit.

During this investigation, LPA obtained a copy of the staff roster and resident roster, reviewed files for Resident #1 (R-1) through Resident #5 (R-5) and obtained relevant documentation, interviewed Assistant Administrator and Staff #1 (S-1) through Staff # 4 (S-4), interviewed Resident #1 (R-1) through Resident #10 (R-10) and conducted a facility tour.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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-20230523094907

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: 06/01/2023

NARRATIVE

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Allegation: Staff refusing to provide resident with medical/physician contact information. Staff interviews (4) out of (5) revealed that Residents are provided with a copy of their face sheet which includes their medical physician’s contact information along with a list of their medication upon request. Per staff interviews, R-5 has been provided with R-5’s face sheet and list of medication multiple times. Staff interviews revealed that R-5 underwent a medication change which was documented and that the new medication has been provided to R-5 as prescribed. Staff interviews revealed that R-5 is forgetful and requires reminders and redirection when requesting for medical physician’s contact information, requesting a list of medication and with medication administration. Resident interviews revealed that staff do not refuse residents the medical/physician contact information. Resident interviews revealed that they consult with their physician’s often and staff provide them with their medication daily. Resident interviews revealed that they are able to obtain their physician contact information and/or their medication list from staff. Interviewed residents do not have any concerns with retrieving their physician’s contact information and/or a list of their medication from staff. Interviews do not corroborate this allegation.

Allegation: Staff not assisting resident with showers. Staff interviews revealed that staff provide assistant to residents with showers (residents that require assistance with Activities of Daily Living (ADLs)). (4) out of (5) staff interviews revealed that R-5 showers independently a couple of times per day and staff are on “standby” when R-5 is showering (in case R-5 requests for assistance). Interviewed staff indicated that residents do not go without staff assistance with showers/baths for (2) months. Resident interviews revealed that staff assist residents with showers. Interviewed residents indicated staff assist residents with showers a couple of times per week. Resident interviews revealed that staff have a “shower schedule” for residents and that staff also assist them on days not noted on the “shower schedule”. Interviewed residents do not have any concerns with staff assisting with showers. Interviews do not corroborate this allegation.

Allegation: Residents bed is in poor condition. Staff interviews revealed that residents’ beds are not in poor condition. Interviewed staff indicated they have not received any concerns from residents in regards to their bed. Staff interviews revealed that R-5 requested a hospital bed versus a regular bed as R-5 was accustomed to having a hospital bed at R-5’s previous residence. Per staff interviews, there has not been any complaints in regards to beds being uncomfortable. Per staff interviews, R-5’s medical professional ordered a hospital bed and R-5 has been provided with the hospital bed. Resident interviews revealed that their beds are in good condition and are comfortable. Interviewed residents do not have any concerns in regards to the condition of their bed. Interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230523094907

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: 06/01/2023

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	Based on record review and interviews conducted the findings indicate, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED. An exit interview conducted, appeal rights and a copy of this report was provided to Lisa Pham.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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