<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602950
Report Date: 07/22/2024
Date Signed: 07/22/2024 12:03:31 PM


Document Has Been Signed on 07/22/2024 12:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MANORFACILITY NUMBER:
198602950
ADMINISTRATOR:NARINE MERTKHANYANFACILITY TYPE:
740
ADDRESS:12045 LAKEWOOD BLVDTELEPHONE:
(562) 923-4417
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:160CENSUS: 120DATE:
07/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Cynthia Flores - AssistantAdministratorTIME COMPLETED:
12:18 PM
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
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit to note additional deficiencies that were found during the complaint investigation. LPA met with Narine Mertkhanyan and explained the reason for the visit.

On 8/25/23 LPA Flores initiated a complaint investigation. During the course of the investigation, it was found that Resident #1(R1) had a restricted health condition. R1’s physician’s report dated: 11/16/20 does not note R1 had dementia. However, on 6/19/23 upon R1’s hospitalization, the hospital noted R1 with dementia. Due to R1’s cognitive skills, R1 was not able to measure blood sugar and/or provide self with injections per regulations for restricted health conditions. During the same hospital visit of 6/19/23, it was found that blood test was highly elevated and “flagged as critical results.” Appraisal/Needs and Services plan dated 7/13/23 does not note any care for R1’s restricted health condition. R1 began receiving home health services on 7/14/23 and there are no records to indicate she was receiving them prior to that date. On 8/25/23 and 5/21/24 LPA conducted complaint investigation visits at the facility and did not find documents related to restricted health condition or provided documents upon request. Therefore, there are no records to indicate that R1 was receiving medication for restricted health condition or a plan to provide care for restricted health condition.

Deficiencies are noted on LIC 809D on per Title 22 Regulations.

Exit interviews was conducted with Cynthia Flores and a copy of this report LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/22/2024 12:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/23/2024
Section Cited
CCR
87628(a)

1
2
3
4
5
6
7
Diabetes: (a) The licensee shall be permitted to accept or retain a resident... if the resident is able to perform his/her own glucose testing... and is able to administer his/her own medication... or has it administered by an appropriately skilled professional.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will certify in writing that will ensure that each resident with a restricted health condition is able to care for self or is under care from a skilled professional to the department by POC due date 7/23/24.
8
9
10
11
12
13
14
Based on interviews and documents reviewed the licensee did not ensure R1 was able to perform own glucose testing or was checked by a skilled profesional which poses an immediate health, safety, or personal rights risk to the persons in care.
8
9
10
11
12
13
14
Request Denied
Type B
07/29/2024
Section Cited
CCR87611(b)

1
2
3
4
5
6
7
General Requirements for Allowable Health Condition: (b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following:

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will create a plan of care for each resident with an allowable health condition and maintain medication records and submit a copy to the department by POC due date 7/29/24.
8
9
10
11
12
13
14
Based on interviews and documents reviewed licensee did not ensure facility maintain a plan of care for R1 who had a restricted health condition which poses a potential risk to health, safety, or personal rights of the persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2