198602950-3-20-2024-28-AS-LHIS-D3ZM4B-20240404091628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:09:55 PM

Unsubstantiated

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
03/19/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240319095008

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: 101	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Narine Mertkhanyan, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable death.
Staff did not ensure resident received adequate care.
Staff allowed resident to be left in soiled clothing for extended periods of time.
Staff did not ensure resident was provided with bathing services.

INVESTIGATION FINDINGS:

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

Licensing Program Analysts (LPAs) Galarza & Tyler Reyes conducted an initial 10-day complaint investigation visit in regards to the allegation listed above. LPA discussed the purpose of the visit with Cynthia Flores. Administrator arrived shortly after.

The investigation consisted of: A physical plant tour of the interior of the facility, record review, and interviews of staff (S1- S6) and residents (R2-R13) were conducted. Resident (R1) passed away and was not interviewed. Resident (R1's) file documents were reviewed. The following documents were obtained: Face Sheet, Preplacement Appraisal Information, Physician's Reports, Home Health Notes, incident reports, Appraisal Needs/Services Plan, LIC 500 Personnel Report, and resident roster.

***See narrative summary on next page.***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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-20240319095008

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: 03/20/2024

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

Allegation: Questionable Death. It is alleged that on December 20, 2023 resident (R1) was found unresponsive and not breathing in their room. According to information obtained the resident died Pneumonia due to COVID-19, and R1's family was not aware that the resident was ill. Based on interviews conducted, the findings indicate that the facility had a COVID-19 outbreak in December 2023, and the facility conducted mass testing of COVID-19 on December 20, 2023, the same day that R1 died. The COVID-19 mass testing results were obtained the following day. Resident (R1) tested positive for COVID-19. A total of six (6) staff were interviewed. Staff stated that the resident tested positive for COVID-19 and died at the facility. Per staff, the resident used oxygen daily and had respiratory pre-existing conditions. Only (1) staff stated that they observed a change in condition approximately 3-4 days prior to R1's death. According to staff, R1 began to speak less, but because the resident required oxygen at all times breathing issues were not noted as a change in condition. LPA obtained the LA County Death Certificate that lists the cause of death as Pneumonia, COVID-19, and Acute Respiratory Failure. Therefore, there is insufficient evidence to corroborate the allegation.

Allegation: Staff did not ensure resident received adequate care. It was reported that sometimes facility staff responded to R1 rudely, mean, and sarcastically when the resident requested assistance. A total of 12 residents were interviewed, of which none reported issues with care services. A total of six (6) staff were interviewed, of which all denied the allegation. According to interviews conducted, resident (R1) frequently pulled the call system string and staff responded in a timely manner to the resident. Resident (R1) was able to transfer to the bed on their own, but was full assist on ADL's. Staff stated that the resident's care needs were not neglected and the resident was treated well. There is insufficient evidence to support the allegation.

Allegation: Staff allowed resident to be left in soiled clothing for extended periods of time. It is alleged that facility staff did not change R1's incontinence diaper as needed, because the resident required a diaper change more frequently than every 2 hours. It was reported that on several occasions R1 was heavily soiled with urine when family visited the resident. All staff interviewed denied the allegation and stated that the resident was changed at least every 2 hours, but often was changed hourly because the resident drank a lot of water and needed more frequent diaper changes. Staff stated that they never received complaints from the resident or responsible parties about incontinence care. A total of 12 residents were interviewed, one (1) resident reported that staff sometimes ignore the call request, and there have been times they wait more than 20 minutes to receive incontinence care. Based on interviews conducted, there is insufficient evidence to corroborate the allegation.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240319095008

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: 03/20/2024

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

Allegation: Staff did not ensure resident was provided with bathing services. It is alleged that resident (R1) was not being bathe as necessary after incontinence incidents. Based on staff interviews, the findings indicate that residents receive baths twice weekly and/or as needed. In R1's case, the resident was often bathe 3 times a week due to bowel incontinence. All staff denied the allegation. A total of 12 residents were interviewed, none reported issues with bathing schedule. Per record review, resident (R1) received regular bathing assistance. Therefore, there is insufficient evidence to corroborate the allegation.

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 was conducted with Administrator Narine Mertkhanyan. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3