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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602950
Report Date: 03/29/2025
Date Signed: 03/29/2025 09:10:34 AM

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
01/28/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250128121742
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: 124DATE:
03/29/2025
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Aracely Curiel - MedTechTIME COMPLETED:
09:15 AM
ALLEGATION(S):
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Staff did not ensure that resident was transported to dialysis appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with Aracely Curiel and explained the purpose of today's visit.

The investigation consisted of the following:
On 2/4/25 LPA obtained copies of staff & resident rosters, copy of transportation log from December 2024 - January 2025, obtained copy of Resident #1's (R1) Physician Report, R1's charting notes, copy of Unusual Incident Report (UIR), Interviewed 5 Staff (S1-S5) and 10 Residents (R1-R10).
On 3/28/25 LPA interviewed R1.
During todays visit 3/29/25 LPA delivered findings.

(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2025
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 2
Control Number 28-AS-20250128121742
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: 03/29/2025
NARRATIVE
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The investigation revealed the following:
Allegation: Staff did not ensure that resident was transported to dialysis appointments.
It is alleged that R1 was missing appointments to their dialysis treatments due to facility not providing transportation. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation stating that transportation is never denied to residents, residents have the option of using the facility van for transportation if it’s communicated with staff that they need it. Interviews with S1-S3 revealed that R1 did have a time where their insurance stopped coverage of transportation to dialysis but once it was observed the facility began providing R1 with transportation to appointments. LPA interviewed 11 residents and 11 out of 11 residents denied the above allegation, stating that they have never been denied transportation and have not had issues with staff assisting with transportation at the facility. LPA interviewed R1 and R1 stated they had a short time where insurance did not cover their transportation, facility staff began providing the transportation once it was observed and staff also assisted with fixing the issue with the insurance.

Based on statements and interviews conducted with staff/residents, and review of R1's files, there was not enough supportive evidence to concur with the reported 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 held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2025
LIC9099 (FAS) - (06/04)
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