198602950-7-1-2021-28-AS-CYEE-C4V38Z-20210712180220

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 04/07/2021
Date Signed: 07/01/2021 02:32:36 PM

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
01/07/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210107170621

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: 115	DATE:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Elizabeth Martinez		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility staff and/or residents are leaving used PPE equipment and litter in the community.

INVESTIGATION FINDINGS:

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***Note: This is an amended version of the report dated 4/7/21. The report was amended to conceal the gender of the party involved.***
Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Elizabeth Martinez, the facility case manager.
On 1/15/21, LPA Spencer conducted a Facetime video call which consisted of a review of the physical plant including the front entrance, parking structure, backyard areas, and surrounding neighborhood. During the course of the investigation, LPA Spencer conducted telephone interviews with assistant administrator Cynthia Flores, staff #1-4 (S1-S4), and residents #1-10 (R1-R10). R2, R3, and R10 declined to be interviewed, so 7 resident interviews were completed. The LPA received and reviewed copies of the Staff Roster, Resident roster, trash pickup schedule, PPE disposal policy, and job duties.
***See LIC9099C for continuation of this narrative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

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-20210107170621

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: 04/07/2021

NARRATIVE

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***Note: This is an amended version of the report dated 4/7/21. The report was amended to conceal the gender of the party involved.***

The investigation revealed the following:

Facility staff and/or residents are leaving used PPE equipment and litter in the community.
It was alleged that litter and used PPE is being improperly discarded on the ground and enters the surrounding neighborhood. In interview, a witness (W1) indicated that W1 was unsure whether the litter was coming from Lakewood Park Manor because there are two other facilities nearby including a health care center and another residential care facility for the elderly (RCFE). During the tour on 1/15/21, LPA Spencer did not observe trash, litter, or used PPE outside of Lakewood Park Manor or in the surrounding areas. LPA observed that Lakewood Park Manor's entrance opened up to a street (Lakewood Blvd), and that the parking lot was self-contained. Interviews with the assistant administrator reveal that staff dispose off PPE gear before exiting a positive resident's room and face masks are disposed of in trash cans located throughout the facility. 4 out of 4 staff interviewed stated that they have not seen litter or used PPE outside of Lakewood Park Manor but S2-S4 stated that they have seen trash coming from the health care center nearby. 5 out of 7 residents stated that they have not observed or heard about a litter problem and that the surrounding areas are generally clean. A review of the trash pick-up invoice/schedule shows that the facility contracts with a company for trash disposal 5 times a week. A review of the job duties shows that staff are also trained on how and where to dispose of trash properly.

Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.

A telephonic exit interview was conducted with facility case manager Elizabeth Martinez. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

LIC9099 (FAS) - (06/04)

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