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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602950
Report Date: 06/30/2026
Date Signed: 06/30/2026 03:29:58 PM

Document Has Been Signed on 06/30/2026 03:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MANORFACILITY NUMBER:
198602950
ADMINISTRATOR/
DIRECTOR:		CYNTHIA FLORESFACILITY TYPE:
740
ADDRESS:12045 LAKEWOOD BLVDTELEPHONE:
(562) 923-4417
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 160CENSUS: 119DATE:
06/30/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Cynthia Flores TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Christian Gutierrez conducted an unannounced Required-1 year visiting using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Cynthia Flores who assisted with today’s visit. There are currently 119 elderly residents, 60 years and older, residing in the facility. The facility is licensed for (160) residents with age range 60 and over. 160 non-ambulatory, of which (5) may be bedridden in rooms 24, 25, 26, 27, and 28. Hospice waiver for 30. This is a three-story residential care facility for the elderly (RCFE). The first floor has a parking garage, lobby, administrative offices, employee lounge, beauty salon, supply room, elevator, outdoor patio, dining room, and kitchen. The 2nd floor includes 40 resident rooms, laundry room, medication room, and activity room. 3rd floor has 40 resident rooms, laundry room, maintenance/storage room, and activity room. There are (2) elevators and at time of visit one is being serviced.

Resident bedrooms were randomly chosen for review 2nd floor (R#7, R#31, R#18, and R#9) and 3rd floor (R#45, R#47, R#67, and R#55). Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The residents’ bathrooms have the required grabs bars and non-skid mat. The hot water was between 107.3-118.6 degrees, which is within the required 105 - 120 degrees. Fire extinguishers were observed throughout the facility. Cleaning supplies and toxic substances are inaccessible to residents in third floor storage room. Kitchen was inspected. There is a sufficient supply of 2-day perishable and 7-day non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the activity room, dining room, living room, and patio areas. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. Evacuation chairs were observed at each stairwell. All required postings were observed throughout the facility. The facility does not have a swimming pool or bodies of water on the premises. Passageways and exits are free of obstruction.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/30/2026
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LPA checked first aid kit that included all of the required items along with the manual. Six (6) staff files were reviewed and included Criminal clearance record, and health screening with TB. Six (6) residents files were reviewed and included physicians report with TB clearance. Two (2) residents were missing pre-appraisal forms, and four (4) residents were missing appraisal needs and service plan LIC 625. Last fire/earthquake drill was conducted in June of 2026. Infectious control plan was reviewed. Random resident medications were reviewed. Medications are centrally stored and locked.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on LIC809-D. Exit interview was held and a copy of the report with appeal rights and LIC9098 was given to Administrator Cynthia Flores.

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NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2026 03:29 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/30/2026 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above two (2) residents did not have a pre-admission appraisal in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2026
Plan of Correction
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Administrator will send LPA appraisal by POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above four (4) residents did not have a appraisal needs and service plan in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2026
Plan of Correction
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Administrator will send residents appraisal needs and service plan LIC 625 by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
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