198602950-6-21-2021-28-AS-MVAO-C4FR5H-20210629124310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 06/18/2021
Date Signed: 06/21/2021 12:06:47 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
06/11/2020 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200611155008

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:	10:00 AM
MET WITH:	Cynthia Flores (Assistant Administrator)		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident sustained a pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted a site visit to delivered complaint findings for the allegations listed above. Upon arrival, LPA met with Cynthia Flores and explained the purpose of the visit.

During the initial investigation on 06/17/20, LPA conducted a health and safety check. LPA toured the facility via Facetime with Cynthia Flores and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Wash basins, showers/bathtubs and toilets are operable. There are no immediate health and safety concerns during the initial investigation.

In regards to the allegation: Resident sustained a pressure injury while in care. The department conducted record review which consist of R#1's Physician's Report and and hospital records and interviewed R#1, R#1's family member and facility Staff #1, #2. Physician's Report dated 04/16/20 did not specify any history of skin condition or breakdown. 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-20200611155008

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 admitted to the facility on 05/01/20 and an initial body assessment was conducted which indicate that R#1's skin was intact. There were no bruises, lacerations, rashes or skin breakage. On 05/21/20, a physical assessment was also conducted on R#1's back and lower body which indicated that there were no redness, pressure injuries or bruising. R#1's legs were intact and no swelling. There was no bruising or lesions on R#1's arms. On 05/27/20, another body assessment was conducted by facility staff and R#1's skin was clear and intact. On 05/29/20, another body assessment was conducted on R#1's upper extremities and revealed that there were no dryness, abdomen was round and soft, skin appears moist. Skin in abdomen and back area had no redness or bruising. No signs of skin breakdown, sores or lesions on the lower parts of R#1's body. The groin area was intact. Legs were not swollen. Interview with R#1's family member had no mention of nor observed any pressure injury or skin breakage to R#1. R#1 was not able to provide specific information regarding the pressure injury. Hospital records dated 06/09/20 (service date: 06/09/20 to 06/22/20) indicated that R#1 has not taken blood pressure medication for 9 days while not in the faciity. Physical examination conducted by the hospital on 06/09/20 did not note pressure injury on R#1's extremity. It wasn't until 06/11/20 when hospital records indicate R#1 had a decubital ulcer. On 06/15/20, a decubitus ulcer on the left buttock and on 06/16/20 a Stage III pressure injury. All while under the care of St. Francis Medical Center.

Based on the departments record review and interviews, 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 copy of this report 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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