198602950-11-8-2024-28-AS-LHIS-DAZPEQ-20241114101528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 11/08/2024
Date Signed: 11/08/2024 01:23:29 PM

Substantiated

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
11/01/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241101154949

FACILITY NAME:	LAKEWOOD PARK MANOR		FACILITY NUMBER:	198602950
ADMINISTRATOR:	NARINE MERTKHANYAN		FACILITY TYPE:	740
ADDRESS:	12045 LAKEWOOD BLVD		TELEPHONE:	(562) 923-4417
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY:	160	CENSUS: 123	DATE:	11/08/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Cynthia Flores, Assistant Administrator		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Lack of supervision resulting in resident eloping from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Assistant Administrator Cynthia Flores. *Note: Administrator on record is not current.

The investigation consisted of: A physical plant tour of all common areas was conducted. Wellness Director/Staff (S1) is off today and was not interviewed. Staff (S2-S4), Skiled Nursing Facility (SNF) staff, hospital staff, and Downey Police officer were interviewed. LPA reviewed and obtained the following documents: Plan of Operation, SNF [Admission Record, Order Summary, Progress Notes, History and Physical, Transfer/Discharge Report, Discharge IDT Recapulation of Stay & Instructions, Resident's Clothing and Possessions, and LIC 602- Physician's Report dated 10/17/2024]. LIC 500 Personnel Report and resident rosters were obtained.

*Narrative continues next page.

Substantiated

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: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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-20241101154949

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: 11/08/2024

NARRATIVE

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Allegation: Lack of supervision resulting in resident eloping from facility. It was reported that on 10/31/2024, resident (R1) was found wandering the streets in a very confused state and was transported to the hospital at 7:39 PM. According to information obtained, on 10/31/2024 two (2) Skilled Nursing Facility (SNF) escorted resident (R1) to the facility as pre-planned by facility staff and SNF care team, and the resident was received by Wellness Director/staff (S1) at 4:42 PM. Based on staff interviews, resident (R1) was transferred to the facility, and as Assistant Administrator was reviewing admission agreement the resident walked out the door. Wellness Director/staff (S1) attempted to redirect and followed him a short distance, but the resident refused to return to the facility. Staff (S1) is not on shift today and was not interviewed. Three (3) other staff were interviewed. Assistant Administrator/staff (S2) and another Wellness Director/staff (S3) stated that the facility did not consider resident (R1) a resident because the resident refused to sign admission documents. Per Health and Safety code §1569.2 (c) Definitions. “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered....The resident was received by staff (S1) at 4:42 PM.

Per record review of SNF discharge documents provided to the facility, R1's Physician's Report states the R1 has Dementia and metabolic encephalopathy. The SNF Admission Record states R1 has difficulty walking and muscle weakness and "does NOT have the capacity to understand and make decisions". LPA interviewed SNF staff, hospital staff, and Downey Police Department personnel. The findings indicate, that facility staff did not call the police department after unsuccessful attempts to redirect the cognitively impaired resident. Downey Police Department received a phone call at 6:15 PM from a passerby stating a male was found wandering the streets off of Lakewood Blvd and Margaret St in a confused state. The passerby reporting party stood by until the Police Department arrived. Therefore, there is sufficient evidence to corroborate the allegation because facility staff neglected responsibility in ensuring the resident's safety.

Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D.

An exit interview was conducted with Assistant Administrator Cynthia Flores. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241101154949

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/13/2024 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	§1569.2 (c) Definitions. “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.... This requirement was not met evidenced by:	1 2 3 4 5 6 7	Licensee shall submit by tomorrow a written plan of correction, that includes facility procedures when admitting a cognitively impaired resident. Submit proof by 11/13/24 that all staff were trained in Dementia wandering behavior, methods of redirection and care and supervision responsibilities.
	8 9 10 11 12 13 14	Based on record review, on 10/31/24 two (2) SNF CNAs escorted R1 to RCFE with belongings, discharge documents, and medications. R1 was received by staff at 4:42 pm. At 6:15 pm a passerby called police department to report they found a cognitively impaired male wandering the streets. This posed and immediate health and safety risk to 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC9099 (FAS) - (06/04)

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