198602950-7-22-2024-28-AS-RORN-D7PUSR-20240731155046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 07/22/2024
Date Signed: 07/22/2024 11:59:01 AM

Substantiated

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
08/15/2023 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230815130109

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:	07/22/2024
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Cynthia Flores - Assistant Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff neglect let to resident sustaining wounds
Staff did not notify authorized representative of residents wound which resulted in hospitalization
Staff did not provide timely medical care for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit at the facility to deliver findings for the above allegations. LPA met with Cynthia Flores and explained the reason for the visit.

The investigation consisted of the following: On 8/17/23 LPA Flores and Margaryan conducted a Health and Safety check and tour the facility no deficiencies were observed. LPAs requested copies of staff/resident roster and resident #1(R1)’s Physician's Report, Admission Agreement, Face Sheet, resident appraisal, Appraisal/Needs and Service plan. On 8/16/23 Investigation Bureau assigned the investigation to investigator Olivia Spindola. On 8/17/23 Wound notes were emailed to LPA Flores. On 3/21/24 LPA Flores subpoena medical records. On 5/21/24 LPA Flores conducted a subsequent complaint investigation visit at the facility and conducted interviews with staff and residents. On 7/22/24 LPA conducted a complaint investigation visit and deliver findings.
(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20230815130109

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: 07/22/2024

NARRATIVE

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The investigation revealed the following: Regarding allegations: Staff neglect let to resident sustaining wounds, Staff did not notify authorized representative of resident’s wound which resulted in hospitalization, and Staff did not provide timely medical care for resident. It is alleged R1’s representative noticed a wound on R1’s foot, staff facility was notified by R1’s representative of wound who agreed to have in-house physician follow up, wounds have been present for several months, and R1’s representative did not receive any update regarding foot wound. On 6/13/23, R1’s family member visited R1 at the facility. Family member assisted R1 with a shower and noticed R1 had a wound. On 6/13/23, R1’s representative was notified by family member of wounds and representative then notified staff #2 (S2) via email of the wound on R1’s left heel. S2 replied that they will assist R1 with medical attention. On 6/19/23, R1 was send out to the hospital due to complaints of pain. On 6/22/23, R1 was discharge from the hospital to a skill nursing facility (SNF) for care. On 7/12/23, R1 was discharge from SNF and returned to the facility. On 7/14/23, R1 initiated home health care. On 7/20/23, wound care agency evaluated R1 and noted R1’s wound still open which measured 3.5cm by 3.5cm. On 7/22/23, R1 was transferred from the facility to a SNF for care.

Interviews conducted with facility staff revealed, that facility staff were aware that R1 had developed left foot wound, and three staff stated the wound in R1’s left heel was present for several weeks. Per Incident report dated: 6/19/23 staff contacted wound specialist regarding R1’s left heel wound, who recommended triple antibiotic ointment and recommended to send R1 to the hospital. Medical records reviewed, revealed R1 was seen at the hospital on 6/19/23 for a wound on the left heel. The wound was described as a “left heel wound with black color”. Hospital also noted on the history that paramedics stated resident was brought to the hospital for “evaluation of a wound on the left foot which has progressively worsen and the wound has been present for about a week, increasingly red and swollen.” On 7/26/23, Wound Care services noted a wound on “Left, Lateral Heel is a Wagner Grade 1 Diabetic Ulcer and has received a status of Not Healed.” The wound’s measurements were 3.5cm length x 3.5cm width x 0.1cm depth. Based on the interviews conducted and documents reviewed facility staff were aware of the wounds before the hospitalization on 6/19/23, R1’s representative notified S2 on 6/13/23 of the wound, there is documentation that a wound specialist recommended R1 to go out to the hospital, R1 went out to the hospital on 6/19/23, six days after the wound was reported to staff, and family representatives were not communicated regarding the wounds either prior to 6/19/23 or after.

(CONTINUED ON LIC 9099C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20230815130109

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: 07/22/2024

NARRATIVE

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Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #1 sustaining a wound to the left heel, worsening due to health conditions, and facility staff not seeking medical attention in a timely manner while in care. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect.

Exit interview was conducted with Cynthia Flores and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20230815130109

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 07/23/2024 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a)...: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will certify in writing that staff including administrator will follow up on any medical need upon observation, communication, or discovery of such, and will provide training to staff on the above and submit trainig logs to the department by POC due date of 7/23/24.
	8 9 10 11 12 13 14	Based on interviews conducted and documents reviewed licensee failed to ensure R1 did not develop a wound which poses an immediate risk to the health, safety, or personal rights to the persons in care. Immediate Civil Penalty for $500 is being issue	8 9 10 11 12 13 14
Deficiency Dismissed Type A 07/23/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately... (a)... :(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will provide training to staff regarding reporting, seeking medical attention, and assisting residents in a timely manner and will submit logs to the department by POC due date 7/23/24.
	8 9 10 11 12 13 14	Based on interviews conducted and documents review licensee did not ensure R1 received medical attention in a timely manner which poses an immediate risk to the health, safety, or personal rights to the persons in care. Immediate Civil Penalty for $500 is being issue	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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230815130109

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 07/29/2024 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities:(a) Residents...shall have...:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will maintain communication with resident's representatives in writing, and will provide a training to staff to ensure that communication is properly log in the charting notes by POC due date 7/29/24.
	8 9 10 11 12 13 14	Based on interviews and document review licensee did not ensure that R1's family were informed of the wound development which poses a potential risk to the health, safety, or personal rights to the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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