198602950-3-7-2024-28-AS-TVAO-D3AMQ8-20240312094815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 03/07/2024
Date Signed: 03/07/2024 10:15:12 AM

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
09/12/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220912163936

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:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Cynthia Flores, Assistant Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to provide medical attention in a timely manner.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to deliver findings for the allegation above. LPA arrived and met with Assistant Administrator, Cynthia Flores, to explain the reason for the visit.

The investigation consisted of the following:
On 9/21/22, LPA Chan conducted the initial visit to gather rosters and documents pertaining to Resident #1 (R1). Interviews were conducted with the Assistant Administrator, 4 Staff, and 5 Residents. On 2/2/23, LPA interviewed the administrator, 2 staff and 6 residents.

The investigation revealed the following:
Allegation – Facility failed to provide medical attention in a timely manner. It was alleged that Resident #1 (R1) requested medical attention but was delayed 48 hours which resulted in resident losing 3-6 liters of blood.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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 2

Control Number 28-AS-20220912163936

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: 03/07/2024

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

LPA interviewed a total of 8 facility personnels, 11 residents, and reviewed documents to determine the findings for this allegation. According to staff interviews, R1 has a history of menstrual bleeding. Some staff stated they assisted R1 with changing the pad when R1 requested help. Staff did not observe substantial bleeding from R1 that appeared alarming when they showered or changed R1. They also stated R1 mainly requested help with bathing and changing and did not share the medical history with staff. However, when R1 requested the facility’s help in arranging medical appointment, staff did so.

For this incident, staff recalled checking on R1 during their shifts and did not see any signs of distress on R1 days prior to hospitalization. When R1 reported feeling weak, the staff asked if 911 should be called. Per R1, resident did not want them to contact 911, but rather, to arrange for a telehealth visit. Staff assisted with the request and R1 spoke with the doctor. Per the physician’s recommendation, R1 should be evaluated at the hospital and staff tried to assist in arranging non-emergency transportation. Staff informed R1 there were no bariatric transportation on that day and will continue to find one. In the meanwhile, R1 did not disclose to staff about the menstrual bleeding nor symptoms that required immediate medical attention until the next day. Staff immediately called 911 when R1 requested it. Based on information gathered, R1 appeared to be self-independent with medical needs and did not fully share the medical history with the facility. Staff could not have known the significant amount of blood loss.

LPA interviewed a total of 11 residents. 7 out of the 11 residents, who need some assistance from staff, indicated that staff assisted right away when they asked for help. Some residents, who had requested medical attention, stated that staff provided medical attention in a timely manner.

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.

An exit interview was conducted with Cynthia Flores. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2