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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 01/30/2025
Date Signed: 01/30/2025 05:09:36 PM

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
12/26/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241226093704
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: 126DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Narine Mertkhanyan TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are unable to provide adequate care and supervision for the residents during a power outage
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 1/30/2025, to deliver findings. LPA Ramirez was greeted by back-up Administrator Narine Mertkhanyan and explained the purpose of the visit. Initial complaint investigation visit was conducted on 12/31/2024 and needs further investigation was documented.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), Resident Roster, Staff#1-9 interviews (S1-S9), Resident interviews#1- 11 (R1 – R11), Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E) , Face Sheets for Residents 1-11 (R1-R11), Physician’s Orders for Residents 1-11 (R1-R11), and physical plant tour.

SEE 9099-C for continued report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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 6
Control Number 28-AS-20241226093704
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: 01/30/2025
NARRATIVE
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The investigation revealed the following. Regarding Allegation: Staff are unable to provide adequate care and supervision for the residents during a power outage- It is alleged facility staff were unable to provide adequate care and supervision during a power outage on 12/24/2024. Resident interviews revealed on 12/24/24 the facility experienced a massive power outage from 1:30pm till 2am on 12/25/2024. According to the facility Emergency and Disaster Plan for residential care Facilities for the Elderly (610E), the facility emergency plan indicates “Back generator will automatically operate in case of an emergency power shut off. The generator is southwest of the building in the patio area. Facility is also equipped with flashlights. There will be a rotation and residents will be assigned with care members who will be constantly checking on residents and their needs.” Resident interviews revealed the facility automatic generator did not automatically turn on when the power went out. Resident interview revealed R2 lit a candle in their room as a source of lighting. Six (6) out of eleven (11) residents interviewed revealed staff did not check-in them constantly during the power outage. Nine (9) out of the nine (9) staff interviewed denied this allegation. Staff interviews revealed the facility automatic generator has been in disrepair and did not automatically turn on when the power went out. Staff revealed the facility did have two (2) portable generators on site but, staff was only able to get one (1) of the generators running. This portable generator powered hallway lights in the facility 2nd floor, 3rd floor, temporary string lighting in the dinning room and some oxygen machines if needed. Resident interviews revealed they were left in the dark while in their rooms, but the dinning room and front entrance of the facility was equipped with portable lighting. According to staff interviews, since the emergency pull cords were not functioning, residents that had cellphones had to call the front office cellphone for assistance. On 12/31/2024, LPA Ramirez conducted a physical plant tour and observed the facility generator located in the southwest of the facility to be in disrepair. As a result of the automatic generator being in disrepair, residents were left in the dark in their rooms with no heating, several staff were observed to be using their own cellphones to provide lighting while they worked, and emergency pull cords were not functioning, and residents that had cellphones had to call the facility front office cellphone for assistance. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

One (1) deficiency was cited during this investigation. Exit interview was conducted. A copy of this report, 9099-D, and appeals rights was provided via email.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
12/26/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241226093704

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: 126DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Narine Mertkhanyan TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff allowed residents to be soiled while in care.
Staff did not meet a resident's hygiene need while in care.
Staff did not provide adequate food service.
Staff left a resident unattended.
Staff did not provide laundry services for a resident while in care.
Staff administered medication without proper consent.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 1/30/2025, to deliver findings. LPA Ramirez was greeted by back-up Administrator Narine Mertkhanyan and explained the purpose of the visit. Initial complaint investigation visit was conducted on 12/31/2024 and needs further investigation was documented.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), Resident Roster, Staff#1-9 interviews (S1-S9), Resident interviews#1- 11 (R1 – R11), Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E) , Face Sheets for Residents 1-11 (R1-R11), Physician’s Orders for Residents 1-11 (R1-R11) Medication Administration Record (MAR) for R3, and physical plant tour.

SEE 9099-C for continued report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20241226093704
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: 01/30/2025
NARRATIVE
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Staff allowed residents to be soiled while in care- It is alleged facility staff allowed Resident#3 (R3) to remain soiled during the power outage. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. R3 denied this allegation during interview. On 12/31/2024, LPA Ramirez conducted a physical plant tour and did not observe residents to be malodourous. LPA Ramirez toured resident rooms and observed resident beds to contain proper linen. Although the allegation 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.

Staff did not meet a resident's hygiene need while in care- It is alleged staff did not meet residents’ hygiene needs. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. On 12/31/2024, LPA Ramirez conducted a physical plant tour and did not observe residents to be malodourous. LPA Ramirez observed sufficient hygiene supplies in the facility supply/stockroom. Although the allegation 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.

Staff did not provide adequate food service- It is alleged staff did not provide adequate food service during the power outage on 12/24/2024. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Residents revealed the facility provided them with a hot meal during the power outage for dinner and snacks later on in the evening. Although the allegation 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.

Staff left a resident unattended- It is alleged staff left R3 unattended during the power outage on 12/24/2024. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Interview with R3 revealed staff did not leave R3 unattended on 12/24/2024. R3 revealed staff did check in on R3, two or three times during the power outage. Although the allegation 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.

SEE 9099-C for continued report.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20241226093704
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: 01/30/2025
NARRATIVE
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Staff did not provide laundry services for a resident while in care- It is alleged the facility washing machines were in disrepair during the power outage. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Staff interviews revealed the laundry room was temporarily closed on 12/24/2024 from 2pm till 2am on 12/25/2024 due to the power outage, but the washing machines and dryers were not in disrepair. On 12/31/2024, LPA Ramirez conducted a physical plant tour and observed all washing machines and dryers to be operational. Although the allegation 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.

Staff administered medication without proper consent- It is alleged staff administered R3 a medication without a physician’s order. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. LPA Ramirez reviewed R3’s charting notes for December 2024, Medication Administration Record (MAR) for December of 2024 and physician’s orders. LPA Ramirez did not observe any discrepancies. Although the allegation 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.

No deficiencies were cited for this investigation. Exit interview was conducted. A copy of this report was provided via email.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20241226093704
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: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/31/2025
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations. This requirement was not met as evidenced by
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Back-up Administrator Mertkhanyan agreed to revise the facility Emergency Disaster Plan and will submit this plan by 2/6/2025. Administrator Mertkhanyan will certify a plan to submit revised Emergency Disaster Plan by 1/31/2025.
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Facility automatic generator was in disrepair during power outage and staff did not constantly check-in on residents per facility emergency disaster plan, which caused unsafe and uncomfortable acccommodations. This poses a potential risk to the health, safety, or personal rights of persons in care.
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Type B
09/28/2025
Section Cited
CCR
87303(a)
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a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Administrator will develop plan that will address how the backup generator will be repaired, replaced or removed. Plan must be received by 9/28/25.
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Staff were aware the facility automatic backup generator was in disrepair. This poses a potential risk to the health, safety, or personal rights of persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6