198602950-6-13-2024-28-AS-VMAO-D67UVL-20240613155517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602950
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:55:25 PM

Document Has Been Signed on 06/13/2024 03:55 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LAKEWOOD PARK MANOR		FACILITY NUMBER:	198602950
ADMINISTRATOR/ DIRECTOR:	NARINE MERTKHANYAN		FACILITY TYPE:	740
ADDRESS:	12045 LAKEWOOD BLVD		TELEPHONE:	(562) 923-4417
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY: 160		CENSUS: 125	DATE:	06/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Administrator Narine Mertkhanyan		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA's) Tyler Reyes and Valeria Maldonado 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 Narine Mertkhanyan and assisted LPAs with the visit. There are currently 125 elderly residents, 60 years and older residing in the facility. The first floor has a parking garage, lobby, administrative offices, employee lounge, beauty salon, supply room, 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) operable elevators. The following 12 (CARE) tools domains were utilized during the inspection. Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents medications. Staff are cleaning and disinfecting throughout the day. Operational Requirement: The facility is licensed for (160) residents with age range 60 and over. 160 non-ambulatory, of which (5) may bedridden in rooms 24, 25, 26, 27, and 28. Hospice waiver for 30. Facility has the appropriate liability insurance. Physical Plant and Environmental Safety: There are a total of 80 rooms in the facility which each has there own restroom. LPAs toured the common areas, kitchen, dinning area, public restrooms, and outside areas. Resident bedrooms had the required furniture for comfort and safety and had sufficient lighting. All indoor and outdoor passages were free from obstruction. Private resident bathrooms were inspected. Restrooms were clean, toilets and water faucets worked properly and properly supplied. During the tour of the physical plant, LPA's observed the laundry rooms on the 2nd and 3rd floor open with cleaning supplies accessible to residents in care. LPA's informed staff of the open doors and the doors were closed. However, after passing by the laundry room again, the door was again opened with cleaning supplies still accessible. Continued on LIC 809-C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LAKEWOOD PARK MANOR	FACILITY NUMBER: 198602950
	VISIT DATE: 06/13/2024

NARRATIVE

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Water temperature was measured throughout the residents bedrooms and temperatures ranged from 110 -119 degrees F which is within required range of 105-120 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. Last Emergency Disaster Drill was conducted on 5/17/24. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers were observed to be fully charged.

Staffing: The facility has sufficient staffing in the facility. The facility has at least one person to have updated First Aid and CPR training certificate.

Personnel Records-Training Information: Staff has criminal record clearance. Staff have current CPR/first aid training.

Resident's right/Information: The facility has Personal Rights Poster stationed in the main hallway. Facility provided internet and telephone access for the residents in care. Facility provides internet and telephone access to the residents.

Planned Activities: There is a designated activity poster for the month of June observed in the dinning room.

Food Service: The kitchen was observed for the ability to prepare and serve food. LPAs observed an appropriate food supply of two (2) days of perishables and one week (7) days of non-perishables.

Incidental Medical and Dental: Medications for resident are stored in the facility Medication room. All medication observed during visit were properly labeled in their original containers. Staff designated to administer medication has the proper annual training on file.

Resident's Records-Incident Reports: A total of (5) residents files were reviewed. Required documents were observed.

Continued on LIC 809-C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LAKEWOOD PARK MANOR	FACILITY NUMBER: 198602950
	VISIT DATE: 06/13/2024

NARRATIVE

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Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation.

LPA conducted 4 staff interviews and 5 resident interviews during today's visit.

Resident with Special Health Needs: Facility has hospice waiver for 30 persons there are currently no persons with hospice residing at the facility. There is proper fire clearance and signs posted residents using oxygen.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC809-D page.

Exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/13/2024 03:55 PM - It Cannot Be Edited

Created By: Valeria Maldonado On 06/13/2024 at 03:27 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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87309(a)

Storage Space

(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
1 2 3 4	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.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	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.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Fernando Fierros

LICENSING EVALUATOR NAME:

Valeria Maldonado

LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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