198602950-9-6-2024-28-AS-RORN-D92MMU-20240912094430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 09/06/2024
Date Signed: 09/06/2024 10:01:31 AM

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
01/11/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240111153633

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: 120	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Cynthia Flores, Administrator		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulted in resident sustaining a fracture while in care.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Galarza & Mayra Cota conducted a subsequent complaint visit to deliver findings on the above allegation. The investigation was completed by DSS/CCLD Investigations Branch (IB) Investigator Laarni Santiago. The purpose of the visit was explained to Assistant Administrator Cynthia Flores.

The investigation consisted of: On 1/12/2024, LPA Nicol Wesley conducted a health and safety check and reviewed and obtained relevant documents pertaining to resident (R1), as well as a resident roster and staff roster. No health and safety concerns were observed during that visit. Investigator Santiago obtained medical records and interviewed 7 staff, Primary Care Physician, R1's family member, and hospital staff. On 2/28/2024, an interview was attempted with resident (R1) at a higher level facility.Per, R1's family former resident (R1) died at a higher level facility mid-March 2024.

***Narrative summary continues 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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-20240111153633

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: 09/06/2024

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: Lack of supervision resulted in resident sustaining a fracture while in care. It is alleged that resident (R1) had multiple in December 2023 that resulted in a fractured pelvic area. An additional fall occurred on January 7, 2024 after the resident returned from dialysis clinic. DSS Investigator Laarni Santiago conducted interviews with facility staff, resident's family members, and outside sources. Facility and medical records were reviewed and obtained. Medical records verified that R1 fell in December 2023 at the facility and was then admitted to a skilled nursing facility. Upon discharge back to the facility on January 7, 2024 the resident had another unwitnessed fall. Resident (R1) was found by facility housekeeper, whom immediately responded to the resident, and R1 was later transported to the hospital. Interviews with staff and family members verified that resident (R1) was independent with all Activities of Daily Living (ADL's); alert and oriented; able to communicate their needs; and able to navigate around their room and facility independently utilizing a walker/wheelchair. Records corroborated that resident (R1) was self-sufficient. Physician's Report stated that the resident was a fall risk due to weakness from dialysis, pain, with amputated fingers and toes. However, Primary Care Physician indicate that the resident could still manage on their own with minimal supervision. Although, R1 was known to be a fall risk due to their medical condition, the resident was compliant with maintaining the use of their assistive device and staff checked on the resident every two hours and close supervision was received while the resident was in the common area. The facility has a call light system for all residents and R1 always called staff for assistance when needed. Investigator attempted to interview R1 on 2/28/24. Resident (R1) died at a higher level facility mid-March 2024. Based on interviews and record reviews, there is insufficient evidence to prove the alleged violation occurred.

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 Assistant Administrator Cynthia Flores. 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2