198602950-10-12-2023-28-AS-RORN-CWQQNV-20231018121946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:42:52 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
02/04/2022 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220204143051

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: 97	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Cynthia Flores, Lisa Pham		TIME COMPLETED:	04:58 PM

ALLEGATION(S):

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Facility neglected resident and they sustained a fracture while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit and met with Assistant Administrator Cynthia Flores and Administrator Lisa Pham arrived a short time later and assisted with the visit.

The investigation consisted of interviews with seven staff members (S#1-S#7) and ten residents (R#1-R#10, reviewing and obtaining staff and resident rosters from 2022 and current, R1 LIC602A dated 03/25/2021, 02/08/2022, 02/09/2022, R1 face sheet, Appraisal/Needs and services plan for R1 dated 02/08/2022, Preplacement Appraisal Information, Hospital discharge orders dated 02/07/2022, Physicians orders for R1 dated 02/7/2022. SIR dated 02/04/2022, and Admission Agreement.

The investigation revealed the following:

(continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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-20220204143051

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: 10/12/2023

NARRATIVE

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Allegation: Facility neglected resident and they sustained a fracture while in care
Based on interviews conducted and reports reviewed, it was discovered that R1 sustained fracture at or around 7:00AM on 02/03/2022 due to unwitnessed unforeseen fall. R1 was not considered a fall hazard at the time of the fall. According to staff interviews, R1 was complaining of shoulder pain and R1 noticed a bruise on R1 upper arm near the shoulder. Med-Tech and caregiver were notified, and the facility provided observation, and medical attention by in house medical staff to assess R1. The facility immediately contacted R1 Physician and Physician ordered for R1 to be transported to Hospital. R1 was transported to Norwalk Community Hospital on 02/03/2022 at 1:25PM. Facility notified the family. R1 returned to facility on 02/07/2022 with order for half bed rails to prevent slipping from bed. R1 agreed with the order. LPA interviewed 7 staff and all 7 of 7 staff denied the allegations. All staff stated that they are required by facility policy to check on residents every 2 hours but that checks are done more frequent if needed. LPA interviewed 10 residents (R#1-R#10) and all 10 of 10 residents stated they get good attention at facility and could not collaborate the allegation. 9 of 10 residents stated staff check on them during the day and evening and ask if resident needs anything. R1 stated R1 slipped out of bed, R1 stated R1 did not fall. R1 stated R1 was sleeping when R1 slipped out of bed and that staff were not neglectful or at fault. R1 stated facility acted right away and sent R1 to the hospital. R1 stated R1 is very happy at facility and is satisfied with the care R1 receives. R1 stated staff check on R1 frequently and R1 has not slipped out of bed since incident on 02/03/2022. W1 who is family member stated W1 is very happy with the care provided to R1 and was aware of R1 incident on 02/03/2022 as facility did contact W1. Facility updated R1 LIC602A on 02/08/2022 and 02/09/2022 and Appraisal Needs and services plan on 02/08/2022.. There is no evidence that facility neglected R1 at this time.

Based on interviews, observations, and records reviewed, it is determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the assistant Administrator Cynthia Flores and Administrator Lisa Pham and copy of report was provided along with appeal rights. . .

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

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