198602950-9-15-2023-28-AS-RORN-CW4TEE-20230928143948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 09/15/2023
Date Signed: 09/15/2023 02:53:16 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
05/18/2022 and conducted by Evaluator Erik Zaragoza

COMPLAINT CONTROL NUMBER: 28-AS-20220518140116

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: 86	DATE:	09/15/2023
		UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Rebecca Caballero - Receptionist		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident fell while in care
Staff did not notify resident's authorized representative of incidents
Staff did not prevent resident from engaging in inappropriate behaviors
Staff did not safeguard resident's personal belongings
Staff have not moved resident back to his original room

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Teresa Saavedra the receptionist of the facility and explained the reason for the visit. The Administrator Lisa Pham as well as the Assistant Administrator Cynthia Flores arrived shortly thereafter.

The investigation consisted of the following: during the initial visit conducted on 05/24/2022, LPA Alberto Lopez interviewed two (2) Staff Members, two (2) Residents, and also obtained documents from Resident #1 and #2's (R1 and R2) file. During today's visit, LPA Zaragoza reobtained the FACE Sheets for Residents #3-11 (R3 - R11), and an updated Staff and Resident roster. LPA also conducted interviews with Staff #1 - 6 (S1 - S6), along with R3 - R11. LPA attempted to interview R1and R2, however they no longer live in the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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-20220518140116

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: 09/15/2023

NARRATIVE

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The investigation revealed the following: In regards to the allegation that "Resident fell while in care", it is alleged that R1 fell at the facility due to a lack of supervision some time in March of 2022, however specific details were not provided. During interviews with the residents, none of them have corroborated the allegation that residents have fallen due to staff neglect. R8 explained that they once witnessed a fellow resident fall while out in the community, however paramedics were promptly contacted to assist the resident. During interviews with staff, none of them corroborated the allegation. S1 and S3 explained that if the residents cannot get up after a fall or if they hit their head then they contact paramedics immediately to take them to the hospital, and if they are able to get up after they ask one of their nurses to check on the resident to determine if any further action is required. S1 also explained it was never brought to their attention R1 fell within the facility, and also explained that they submit Serious Incident Reports to licensing whenever they do occur.

In regards to the allegation that "Staff did not notify the resident's authorized representative of incidents", it is alleged that neither the passing of R2 nor a fall sustained by R1 was reported to their authorized representatives. During interviews with residents, none of them corroborated the allegation that the staff do not notify their family or authorized representative of any incidents involving them. R4, R6, R7, and R9 all explained that their families are kept informed of any incidents and updates related to them and their stay in the facility. During interviews with staff members, none of them corroborated the allegation that they do not notify responsible parties of serious incidents. S1 and S2 explained that most of the residents are self-responsible and that they do not have a responsible party, but if they do then they are contacted by phone and notified of any and all serious or unusual incidents regarding the resident immediately. Review of the resident's FACE Sheets revealed that the residents interviewed by LPA were self-responsible..

In regards to the allegation that "Staff did not prevent resident from engaging in inappropriate behaviors", it is alleged that R1 was called homophobic and racial slurs by another resident within the facility and that staff have not done anything to deescalate the situation. During interviews with the residents, eight (8) out of nine (9) residents stated that they have not encountered or witnessed any form of verbal harassment or abuse amongst the residents. R5 stated that they have been the subject of another residents harassment by the residents staring at them and bumping into R5's wheelchair intentionally, however R5 explained that they have not brought the situation up to staff because they think the harassment is petty. During interviews with staff, none of them corroborated the allegation that they do not prevent residents from engaging in inappropriate behaviors.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220518140116

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: 09/15/2023

NARRATIVE

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S1 explained that in the event harassment amongst residents occurs they would first intervene to separate them and diffuse the situation, and work to set limits between the residents. S1 also explained that if one of the residents are harassing others due to behavioral issues then they will move forward with bringing in a psychiatrist to evaluate the resident.

In regards to the allegation that "Staff did not safeguard resident's personal belongings", it is alleged that after R1 moved to their temporary room, their microwave, fridge, and glasses were discarded or lost and never replaced. During interviews with residents, none of them stated that that they have had any of their personal items get stolen or go missing from their rooms. During interviews with staff members, none of them corroborated the allegation that they do not safeguard the personal belongings of residents. S1 explained that if an item from the Resident's inventory list goes missing, they work to find the item and if they cannot they replace it and also possibly file a police report depending on the value of the item. S1 and S2 also explained that R1's fridge was certainly brought along with him during his move to his new room, and they were never notified of his microwave or glasses going missing during the move.

In regards to the allegation that "Staff have not moved residents back to their original room", it is alleged that R1 was asked to move out of their room due to a maintenance problem into a temporary room, however they were never allowed to move back into their original room. During interviews with the residents, none of them corroborated the allegation that they were refused to move back into their room of preference. R10 and R11 explained that they have been asked to move to another room while living in the facility, however they were satisfied with the new room that they were moved into and had no complaints. During interviews with staff members, none of them corroborated the allegation. S1 explained that if a resident is ever relocated to another room temporarily due to a maintenance issue, they make sure remove any non-damaged personal items, and if the resident requests to be moved back into their original room they can. S3 explained that whenever a residents move rooms, it is by request only.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

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