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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 10/28/2022
Date Signed: 10/28/2022 02:33:22 PM

Substantiated


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
10/21/2022 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221021171027
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: 109DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Assistant Administrator, Cynthia FloresTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not provide resident's authorized representative records in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena initiated a complaint investigation for the allegation listed above. LPA Pena was greeted by Asst. Administrator Cynthia Flores and explained the purpose of today's visit.

During today's visit, LPA Pena obtained copies of the Staff/Resident Roster, R1’s Identification and Emergency Information, conducted interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3) by phone, former resident #1 (R1), RP, Witness #1 (W1) and Witness #2 (W2). LPA also received copies of fax request sent by the legal services company (10/24/2022 received at 7:16am), fax confirmation receipts and R1’s records/documents sent by the facility to RP.
******CONTINUATION ON LIC 9099-C********
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
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 3
Control Number 28-AS-20221021171027
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: 10/28/2022
NARRATIVE
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Regarding the allegation: Staff did not provide resident's authorized representative records in a timely manner.

It was alleged that RP requested records on behalf of R1 on 10/06/2022 and have not received anything as of complaint reporting date, 10/21/2022. Based on interviews and records review done by LPA, the investigation revealed the following:


· 10/04/2022 (6:55pm) - RP sent email request via 3rd party legal services.
· 10/06/2022 - legal services company received the request from RP. Witness #1 (W1) from legal services company called the facility and received information where to send/fax it to. Faxed it same day and received confirmation that it went through.
· 10/21/2022 - legal services company called facility to follow up as they have not received anything. W1 stated that someone from their office spoke with Staff #3 (S3) who indicated that she would forward the information to S2. W1 called back on end of day (at 4:24pm), but no response.
· 10/24/2022 - legal services company re-faxed request to facility (at 8:12am) and have not heard back from facility since. However, W1 stated that RP informed them that she will take care of it on her own.

LPA spoke to R1 to confirm that he requested and authorized RP to get his personal/medical records from the facility and she responded: “Yes, I asked them to get it on my behalf, but I cannot remember when exactly.” LPA interviewed RP and stated that she received records/documents from facility on 10/24/2022 (at 4:45pm) after legal services company had called, faxed and emailed the facility multiple times. RP stated that facility should have sent the records/documents to legal services company but since she needed it, she asked the facility to fax it to her directly instead. LPA’s interview with S2 stated that she only received one (1) request and that was on 10/24/2022. S2 does not remember receiving any other request. S2 stated that she normally turns over the request the same day or following day depending if she is in the building. S3 stated that she can not recall a phone call with the specific legal services company on 10/21/2022 or at any day/time. S3 indicated that she gets a lot of calls every day. If she gets that type of call, the normal procedure is to relay it to the appropriate party. LPA interviewed S1 and stated she did not know anything about the fax request that came through on 10/06/2022 and 10/24/2022.


Based on interviews and records review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency under California Code of Regulation, Title 22 is being cited on the attached LIC9099D. Exit interview conducted with Assistant Administrator, Cynthia Flores. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20221021171027
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/04/2022
Section Cited
CCR
87468.2(a)(19)
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87468.2...Additional Personal Rights of Residents...(a) In addition.. (19) To have prompt access to review all their records ...records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.
This requirement was not met as evidenced by:
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Administrator and Asst. Administrator agreed to read, review and understand Title 22 Regulation 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. And release/provide resident's records within two (2) business days.
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LPA Pena's interviews and records review revealed that the facility did not release and provide the resident's records to the authorized requesting party within two (2) business days as required.
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Administrator and Asst. Administrator will send a signed statement stating that they have read, reviewed and understood the regulation 87468.2 to LPA on or before POC due date.
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3