LAKEWOOD PARK MANOR

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 07/07/2026 Plan of Correction Administrator will send LPA appraisal by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 07/07/2026 Plan of Correction Administrator will send residents appraisal needs and service plan LIC 625 by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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. Based on observations, interviews and records reviewed, R1's room was being treated for bed bugs on 01/28/26.

Official plan of correction

*Facility provided proof of pest control service report dated 01/28/26 for bed bug treatment. No further action required. Administrator stated to LPA Gutierrez that the facility would inspect stored mattresses and headboards before bringing into facility.

Deadline recorded: May 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

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.

Deadline recorded: Jan 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Sep 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.2(c)

Regulation authority

HSC

What the official deficiency says

§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: 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.

Official plan of correction

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.

Deadline recorded: Nov 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

Diabetes: (a) The licensee shall be permitted to accept or retain a resident... if the resident is able to perform his/her own glucose testing... and is able to administer his/her own medication... or has it administered by an appropriately skilled professional. This requirement is not met as evidence by: Based on interviews and documents reviewed the licensee did not ensure R1 was able to perform own glucose testing or was checked by a skilled profesional which poses an immediate health, safety, or personal rights risk to the persons in care.

Official plan of correction

Administrator will certify in writing that will ensure that each resident with a restricted health condition is able to care for self or is under care from a skilled professional to the department by POC due date 7/23/24.

Deadline recorded: Jul 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87611(b)

Regulation authority

CCR

What the official deficiency says

General Requirements for Allowable Health Condition: (b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure facility maintain a plan of care for R1 who had a restricted health condition which poses a potential risk to health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator will create a plan of care for each resident with an allowable health condition and maintain medication records and submit a copy to the department by POC due date 7/29/24.

Deadline recorded: Jul 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities (a)...: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by: Based on interviews conducted and documents reviewed licensee failed to ensure R1 did not develop a wound which poses an immediate risk to the health, safety, or personal rights to the persons in care. *Immediate Civil Penalty for $500 is being issue*

Official plan of correction

Administrator will certify in writing that staff including administrator will follow up on any medical need upon observation, communication, or discovery of such, and will provide training to staff on the above and submit trainig logs to the department by POC due date of 7/23/24.

Deadline recorded: Jul 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately... (a)... :(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews conducted and documents review licensee did not ensure R1 received medical attention in a timely manner which poses an immediate risk to the health, safety, or personal rights to the persons in care. *Immediate Civil Penalty for $500 is being issue*

Official plan of correction

Administrator will provide training to staff regarding reporting, seeking medical attention, and assisting residents in a timely manner and will submit logs to the department by POC due date 7/23/24.

Deadline recorded: Jul 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities:(a) Residents...shall have...:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidence by: Based on interviews and document review licensee did not ensure that R1's family were informed of the wound development which poses a potential risk to the health, safety, or personal rights to the persons in care.

Official plan of correction

Administrator will maintain communication with resident's representatives in writing, and will provide a training to staff to ensure that communication is properly log in the charting notes by POC due date 7/29/24.

Deadline recorded: Jul 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2nd and 3rd floor laundry rooms were observed opened with cleaning products accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Administrator Narine Mertkhanyan will provide in-service training to all staff regarding the regulations cited. Sign in sheet and training material provided to LPA by POC Due Date.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by: Based on interviews and documents review, licensee failed to provide additional support for R-1 who failed to comply with medication which posed an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee will submit plan to ensure that any resident non-compliant with medication is addressed immediately to prevent any triggers of aggressive behaviors. The POC is due by 3/3/23.

Deadline recorded: Mar 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

87468.2...Additional Personal Rights of Residents...(a) In addition.. (19) To have prompt access to review all their records ...records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met as evidenced by: LPA Pena's interviews and records review revealed that the facility did not release and provide the resident's records to the authorized requesting party within two (2) business days as required.

Official plan of correction

Administrator and Asst. Administrator agreed to read, review and understand Title 22 Regulation 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. And release/provide resident's records within two (2) business days. Administrator and Asst. Administrator will send a signed statement stating that they have read, reviewed and understood the regulation 87468.2 to LPA on or before POC due date.

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(e)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreement (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification... This requirement is not met as evidenced by: Based on interviews, 6 out of 11 residents did not obtain a copy of the Admission Agreement upon signing the agreement or provided another copy when requested which poses a potential personal rights risk to residents in care.

Official plan of correction

The Administrator shall review regulation 87507 Admission Agreement and provide a copy of the Admission Agreement to all residents and representative. The Administrator shall submit a statement acknowledging this regulation by POC due date 5/24/22.

Deadline recorded: May 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on observation during record review for complaint #: 28-AS-20220128150605; resident (R1) sustained a fall on 1/26/22 that resulted in a knee fracture. The incident report was not faxed to Community Care Licensing (CCL). The last incident report received at CCL was 11/16/21. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee shall submit a written statement that states how this deficiency was corrected. FAX all incident reports that were faxed the wrong number. In addition, submit proof of staff training and attach the training materials.

Deadline recorded: Feb 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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. Based on observation, interviews, and record review, one of the elevators is currently not working which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The licensee shall ensure that elevators are in good repair at all times and will follow up with the elevator service company to obtain time frame for repair. The licensee shall provide LPA a statement with estimated elevator repair date or receipt of completed repair by POC due date 12/31/21. The correction will not be cleared until elevator is repaired.

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87218(a)

Regulation authority

CCR

What the official deficiency says

87218(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety code section 1569.153. This requirement was not met as evidenced by... Based on interviews, the licensee did not ensure that 8 out of 11 residents interviewed had valuables that were adequately safeguarded. This poses a potential risk to the personal rights of persons in care.

Official plan of correction

The administrator stated that they will ensure that the inventory list is accurate, and once a month, the staff will send notice to residents to update their inventory. Administrator stated that she will send a copy of the letter to CCL by POC due date.

Deadline recorded: Dec 13, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(5)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(5) Residents in RCFE's shall have personal rights which include...to be served food of the quality and quantity necessary to meet their nutritional needs. This requirement was not met as evidenced by... Based on observation and interview, the licensee did not ensure that residents were served the quality temperature of food in a timely manner. This poses a potential risk to the health of persons in care.

Official plan of correction

The administrator stated they will divide the serving staff so that some are doing tray delivery and others will do in the dining room. The administrator will create a new policy that states that residents will have no longer than a 30 minute wait for meals.

Deadline recorded: Dec 13, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(15)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(15) (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure that all residents were informed about and received their mail in a timely manner. This poses a potential risk to the personal rights of persons in care.

Official plan of correction

The administrator stated that she will create a self-certified letter that mail will be sorted and residents will be delivered the mail to their room at least once a day on the same day that their mail arrives.

Deadline recorded: Dec 13, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224

Regulation authority

CCR

What the official deficiency says

Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. This requirement is not being met as evidenced by: Administrator, and staff #1-staff #2 stated that resident #1 has not been issued an eviction notice. Administrator, and Staff #1- Staff #2 stated that the facility is not allowing resident #1 to return to the facility, even though he is ready to be discharged from the hospital.

Official plan of correction

Administrator shall abide by Title 22 regulation, 87224 Eviction Procedures. Administrator stated that she will request a 3 day eviction for resident #1.

Deadline recorded: Nov 16, 2021. A deadline is not proof that correction was completed.