198602950-7-14-2023-28-AS-THEA-CTQRYE-20230714132612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602950
Report Date: 07/14/2023
Date Signed: 07/14/2023 01:26:29 PM

Document Has Been Signed on 07/14/2023 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	LISA PHAM		FACILITY TYPE:	740
ADDRESS:	12045 LAKEWOOD BLVD		TELEPHONE:	(562) 923-4417
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY:	160	CENSUS: 96	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	Lisa Pham - Administrator		TIME COMPLETED:	01:40 PM

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	Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Cynthia Flores (Assistant Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 60 and over. 160 non-ambulatory, of which 5 may be bedridden in Rooms 24,25, 26, 27, 28 and hospice waiver for 30. This is a three-story residential care facility for the elderly (RCFE). The first floor has a parking garage, lobby, administrative offices, employee lounge, beauty salon, supply room, elevator, outdoor patio, dining room, and kitchen. The 2^nd floor includes 40 resident rooms, laundry room, medication room, and activity room. 3^rd floor has 40 resident rooms, laundry room, maintenance/storage room, and activity room. There are (2) operable elevators. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: There are a total of 80 rooms in facility which each have room has its own restroom. LPA toured the common areas, 14 resident rooms, kitchen, dining area, public restrooms and outside areas. All rooms that were inspected have private restrooms. Resident bedrooms had the required furniture for comfort and safety and had sufficient lighting. All indoor and outdoor passages were free of obstruction. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied. Water temperature was measured throughout the resident bedrooms and temperatures ranged from 109.4-113.9 degrees F which (Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2023

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

is within the required range of 105-120 Degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in the facility storage on the 3^rd floor. The last Fire/Emergency Drill was conducted on 05/16/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers were observed to be fully charged. The facility is not equipped with delayed egress.
Operational Requirements: The facility accepts bedridden residents and has proper fire clearance for up to 30 (there are currently no bedridden residents). Facility has the appropriate liability insurance.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Lisa M. Pham has a valid administrator certificate that expires on 3/01/2024.
Personnel Records-Training: Staff has criminal record clearance. Staff have current CPR/first aid training and sufficient on-going training.
Resident Rights-Information: The facility has Personal Rights Poster stationed in the main hallway. Facility provides internet and telephone access for the residents in care. Facility provides internet and telephone access to the residents.
Resident Records-Incident Reports: Resident files are kept in a secured location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Planned activities: There is a designated Activities Director that maintains and encourages participation in planned activities.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medications for residents are stored in the facility Medication room. All medication observed during visit were properly labeled and in their original containers. Staff designated to administer medication has the proper annual training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: Facility has a hospice waiver for 30 persons there are currently no persons with hospice residing at the facility. There is proper fire clearance and signs posted for residents using oxygen.
(Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2023

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	LPA conducted 4 staff interviews and 5 resident interviews during today’s visit. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on 809D. Exit interview was held and a copy of the report was provided to Administrator Lisa Pham.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3