198602950-11-21-2024-28-AS-DSIS-DBSTVS-20241209140424

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:52:39 PM

Unsubstantiated

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
11/18/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241118093134

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: 119	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Cynthia Flores - Assistant Administrator		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff threatened resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Cynthia Flores, Assistant Administrator and discussed the purpose of the visit.

The investigation consisted of the following: LPA obtained copies of the Resident & Staff Rosters, Staff In-service training logs for Resident's Personal Rights and Mandated Reporting/Zero Tolerance Policy, Resident #1 (R1) files such as: Information & Emergency Information (Face sheet), Admission Agreement, Physician's Report, Preplacement Appraisal, Personal Rights, Resident Assessment and Unusual Incident/Injury Report (dated 11/14/2024). LPA interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #1 (R1) - Resident #12 (R12).

*****REPORT CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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-20241118093134

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: 11/21/2024

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: “Staff threatened resident." It is alleged that R1 was called in the office and was threatened and intimidated by S1. (5) out of (5) staff interviewed denied the allegation and stated that they respect all residents. All staff interviewed indicated that they don't threaten the residents nor speak to the residents inappropriately. S1 stated that she spoke with R1 to investigate a complaint by S5 against R1, but did not threaten to kick out R1. S5 stated that R1 called him an idiot and stupid, but S5 did not react to avoid confrontation. R1 stated that she was not threatened by S1 but upset that S5 dis-respected her. R1 stated that she gets along well with the staff very well and no one has complained about her before. 11 out of 12 residents interviewed indicated they are happy with staff and they don't feel threatened or dis-respected by staff. Residents interviewed stated that they have not seen or heard of staff threatening other residents. Therefore there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview and a copy of this report was provided to the Assistant Administrator, Cynthia Flores.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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