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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 10/28/2024
Date Signed: 10/28/2024 11:25:44 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/21/2024 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241021160054
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: 138DATE:
10/28/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Rebecca Caballero Receptionist TIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff does not ensure resident has possession of her personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst’s (LPA) Christian Gutierrez conducted an unannounced complaint investigation regarding the above allegations. LPA met Receptionist Rebecca Caballero at approximately 8:00 AM and explained reason for visit. Administrator Cynthia Flores arrived shortly.

The investigation consisted of the following: LPA Gutierrez requested and obtained copies of staff roster (LIC 500), resident roster, R1’s identification and emergency information, admission agreement, residents’ personal property and valuables LIC 621, interview administrator, staff #1-2 interviews (S1-S2), and resident # 3-6 (S3-S6) interviews. Interview with Resident #1 (R1) was conducted telephonically on 10/24/2024. Resident #3 (R3) was unable to be interviewed due to hospitalization stay.

SEE LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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-20241021160054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LAKEWOOD PARK MANOR
FACILITY NUMBER: 198602950
VISIT DATE: 10/28/2024
NARRATIVE
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The investigation revealed the following. Regarding allegation: Staff does not ensure resident has possession of her personal property. It is alleged that R1 did not receive his/her personal property after several request after leaving facility. According to information obtained resident received some items, but a cell phone charger, a clock radio, personal mail, a stay plate for dentures, and a notebook are missing. A total of four (4) residents were interviewed today and four (4) out of four (4) residents stated they have never had any belongs missing or heard that when residents leave that they are missing items. Administrator stated that S2 cleaned out room and took belongings to resident. S2 stated room was completely empty and all items were taken personally to new facility that was confirmed to be new residence of R1.S3 stated when rooms have items at time of cleaning there given to management. A copy of LIC 621 did not list items stated above.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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.

A copy of report was provided to Administrator.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
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