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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 02/20/2024
Date Signed: 02/20/2024 01:26:16 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
02/13/2024 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240213084149
FACILITY NAME:LAKEWOOD PARK MANORFACILITY NUMBER:
198602950
ADMINISTRATOR:LISA PHAMFACILITY TYPE:
740
ADDRESS:12045 LAKEWOOD BLVDTELEPHONE:
(562) 923-4417
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:160CENSUS: 106DATE:
02/20/2024
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Cynthia FloresTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident eloped from the facility because staff did not provide adequate supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a visit to investigate the above allegation. LPA met with Cynthia Flores/S-1 and discussed the purpose of today’s visit.

During this investigation, LPA obtained a copy of the resident and staff rosters, reviewed R-1’s file and obtained relevant information, interviewed Staff #1 (S-1) through Staff #4 (S-4) and interviewed Resident #2 (R-2) through Resident #5 (R-5). LPA was unable to interview R-1 as R-1 has been missing from this facility since 01/28/2024 and R-1’s whereabouts are unknown.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
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-20240213084149
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: 02/20/2024
NARRATIVE
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Allegation: Resident eloped from the facility because staff did not provide adequate supervision. It is alleged that R-1 eloped from this facility due to staff not providing adequate supervision. (3) out of (4) staff interviews revealed that R-1 was in the facility on 01/27/2024 and was reported missing on 01/28/2024. Staff interviews revealed that a missing person’s report for R-1 was filed with the local police department and an incident report was submitted to community care licensing. (3) out of (4) staff interviews revealed that staff continue to have communication with the local police department and local hospitals in attempts to locate R-1.

(3) out of (4) staff interviews also revealed that in October of 2023, R-1 was out in the community for an extended amount of time prior to this latest incident. A missing person’s reports was filed with the local police department and reports were also submitted to community care licensing. Per information obtained, R-1 was located and taken to a hospital for treatment of a medical condition not related to a cognitive impairment.

Staff interviews revealed that R-1 is self-responsible and goes out to the community daily throughout the day independently. R-1’s Physician Report indicates that R-1 does not have a cognitive impairment and R-1 is able to leave the facility unassisted. R-1 only had their initial appraisal/needs and services plan upon admission (dated 12/27/2021) and per S-1, R-1 does not have an updated plan as R-1 has not had a change in condition. Per R-1’s appraisal/needs and services plan, R-1 is self-responsible and is able to perform activities of daily living independently. Interviewed staff indicated that R-1 has not had a change of condition. LPA obtained a chronology for both incidents reflecting the dates the facility called local hospitals and/or local jails in attempts to locate R-1.

(1) out of (4) interviewed residents indicated that R-1 appeared to be their normal self, went in and out of this facility independently and did not appear to have a cognitive impairment. (3) out of (4) interviewed residents indicated they do not know R-1 and that residents keep to themselves. Interviewed staff also indicated that R-1 kept to R-1’s self.

Interviews conducted and documentation reviewed do not corroborate this allegation.

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, a copy of the Appeal Rights and this report was provided to Cynthia Flores.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC9099 (FAS) - (06/04)
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