198602950-1-26-2024-28-AS-RORN-D29NWS-20240208095002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:11:54 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
01/07/2022 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220107103208

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: 111	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Cynthia Flores - Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed injuries (wounds) while in care.
Resident was sent to the hospital without any medical records.
Resident was incorrectly charged for rent.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to investigate the above-mentioned allegations. LPA met with Cynthia Flores, Assistant Administrator and explained the purpose of the visit.
During the initial visit on 01/11/2022, LPA Bonnie Tao toured the facility, reviewed the records of Resident #1 (R1) and obtained a copy of resident roster, staff roster, R1's records such as Identification and Emergency Information, Physician report, Admission Agreement, Appraisal, and Personal rights. LPA Tao also requested a copy of R1's needs and services plan, incident report, dated 1/6/22, and wound care notes.

During today’s visit, LPA Pena obtained the following records/files: Staff & Resident Rosters, Incident report (dated 01/06/22), R1’s records such as Admission Agreement, Face Sheet/ Identification & Emergency Info Sheet, Physician's Report, Resident Appraisal, Needs and services plan, Medical Records, Personal Rights, Wound care notes, Rent increase notification letter and Rent Invoice/Receipt dated 12/16/2021. LPA also interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #2 (R2) - Resident #11 (R11). LPA attempted to interview former Resident #1 (R1) 3x, however, R1's contact information is no longer valid. *****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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-20220107103208

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: 01/26/2024

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

The investigation revealed the following:

In regards to the allegation: “Resident developed injuries (wounds) while in care.” It is alleged that a resident was sent to the hospital after developing wounds on his buttocks. No other details provided. Staff interviewed stated that they do rounds regularly to check on residents. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. Staff also stated that they reposition resident to prevent rashes, sores or wounds. Staff also stated that when caregivers notice rashes or wounds, they report it immediately to the Med Tech for assessment and doctors are notified for treatment and to authorize care from a Home Health nurse or wound care specialist, if needed. LPA interviewed 10 residents of which 2 are incontinence. None of the residents interviewed stated that they have any injuries, wounds nor pain in the buttock area. Some residents interviewed also stated that they never develop wounds under facility's care. LPA reviewed the incident report submitted to CCL dated 01/06/2022 stating that R1 was being treated for the wound and under the care of a wound specialist. Report indicated that the wound specialist ordered R1 to be sent to the hospital because R1 was non compliant with the wound care plan. Based on documentation reviewed, R1 moved into the facility on 12/16/2021 and Preplacement appraisal information indicated that R1 has a history of skin breakdown and was diagnosed with moderate protein calorie malnutrition. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to the allegation: “Resident was sent to the hospital without any medical records.” It is alleged that a resident was sent without any medical records to the hospital. No other details provided. Interviewed staff denied the allegation. Staff stated that mainly, it is the front desk receptionist who prepare the medical records prior to sending a resident to the hospital. Staff also stated that the emergency packet for the residents is located in the front desk and if receptionist is not available Med Tech on duty is responsible for providing emergency packet to paramedics. Interviewed residents denied the allegation and some residents stated that the office staff send them to the hospital with their medical records every time. Some residents also stated that if the facility did not provide it, they will hear it from the hospital personnel, but they never had that issue. Documents reviewed indicated that R1 was sent to the Hospital on 01/06/2022 and a staff provided EMT with R1's report, face sheet and medication list at 6:06pm. Therefore there was insufficient evidence to corroborate with the allegation.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220107103208

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: 01/26/2024

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

In regards to the allegation: “Resident was incorrectly charged for rent.” It is alleged that the rent was for $1200+, which is more than what the resident was told it would and more than the resident's SS check of $1080. Interviewed staff denied the allegation. S1 stated that the rental fee for most SSI recipients increase annually and they notify all residents in advance by writing. S1 indicated that R1 was admitted to the facility on 12/16/2021 and paid a pro rated amount for 12/16/2021-12/31/2021. S1 stated that R1 was notified of the rate increase via letter upon his admission. Interviewed residents stated that they were never charged incorrectly for rent. Residents interviewed stated that the facility notify them of the annual rate increase in advance by letter or memo. Documents reviewed indicated that a notification letter regarding the rent increase was provided to R1 on 12/16/2021 by the Administrator. Additionally, the staff provided R1 an invoice for a pro rated rent between 12/16/2021-12/31/2021. Therefore there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with staff, residents, review of resident 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 allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of the report was provided to Cynthia Flores, Assistant Administrator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3