198602950-6-21-2021-28-AS-MVAO-C4FNKC-20210629103144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 06/18/2021
Date Signed: 06/21/2021 01:02:51 PM

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
10/16/2019 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191016121152

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: 110	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cynthia Flores (Assistant Administrator)		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident developed multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conductd a site visit to deliver complaint findings for the allegation list above. Upon arrival, LPA met with Cynthia Flores and explained the purpose of the visit.

During a site visit on 10/18/19, LPA obtained a copy of the Staff schedule, Resident roster and reviewed records for Residents who are receiving hospice/home health records and records for random Resident.

In regards to the allegation: Resident developed multiple pressure injuries while in care. The Department's investigation, which consisted of interviews with Staff #1 and #2, Resident #1’s (R#1) family members, Resident #2 - #4 and review of R#1 medical records indicated there was no evidence of abuse or neglect upon R#1’s admission to Presbyterian Intercommunity Hospital (PIH) on 10/07/19 and revealed that R#1 was admitted to the hospital for other health concerns. R#1’s hospital records indicate that on 10/07/09 R#1 was admitted to PIH Downey Hospital due to weakness, lethargy and decreased appetite. Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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-20191016121152

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: 06/18/2021

NARRATIVE

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R#1 was later transferred to PIH Whittier Hospital on 10/15/19. During R#1’s hospital stay at PIH Downey Hospital, it was noted that there were numerous unstageable pressure injuries to R#1’s coccyx, toes and heels, however, the photos and staging were dated 10/15/19. The pressure injuries were noted as being stage 2 and/or unstageable and there was no clear indication of the stages of each pressure injury or clarification on whether the staging was the same upon admission to the hospital on 10/07/19. Additional notes indicate pressure injuries to various parts of R#1’s body were at stage I or stage II except for one pressure injury which was unstageable. It was also indicated in R#1 hospital records that hospital staff noted pressure injuries can develop fast, within hours. R#1’s family member reported that nobody observed R#1 having any pressure injuries while residing at the facility. Based on interviews with facility staff, residents and review of R#1 facility records and R#1 medical records dated 10/07/19, R#1’s was admitted to the facility on 09/24/19, a skin assessment was conducted and staff noted R#1 did not have any pressure injury. On 09/29/19 facility notes indicate a small superficial skin tear on R#1’s left buttock due to scratching and treatment was applied. On 09/30/19, small skin tear to the left buttock was noted and treatment was applied. On 10/04/19, staff conducted a body check on R#1 with R#1’s family member present and it was noted that aside from R#1’s buttock area, there was no other skin tears/redness and no open wounds observed. On 10/05/19, facility noted that R#1’s skin was intact, redness was present and no skin breakdown. On 10/07/19, staff checked R#1’s buttock area and noted that R#1 still had a superficial skin tear and the area was cleaned. Interviews with facility Staff #1 and #2 both indicated that Staff #1 and #2 did not notice R#1 to have any pressure injury, only a small superficial skin tear. Based upon the investigation, there is no evidence to support that R#1 developed multiple pressure injuries while in the care of the facility and there is no clear indication as to when R#1’s developed the pressure injuries. It is possible that R#1 pressure injuries may have developed after R#1 was hospitalized on 10/07/19.

Based on the department's interviews and record review, 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.

Exit interview conducted with Cynthia Flores and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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