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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 06/12/2023
Date Signed: 06/13/2023 06:15:05 PM

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
06/08/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230608093038
FACILITY NAME:NORWALK RETIREMENT VILLAFACILITY NUMBER:
198603172
ADMINISTRATOR:CHANEL A. SANCHEZFACILITY TYPE:
740
ADDRESS:11515 FIRESTONE BLVDTELEPHONE:
(562) 379-9200
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:80CENSUS: 67DATE:
06/12/2023
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Chanel A Sanchez TIME COMPLETED:
03:59 PM
ALLEGATION(S):
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Wrongful Eviction.
Staff did not safeguard resident's belongings.
Staff do not ensure that resident is accorded privacy
Staff do not ensure that resident is receiving medical attention as needed.
Staff do not ensure that resident's room is maintained at a comfortable temperature.
Staff do not respond to requests for communication about resident in a timely manner.
INVESTIGATION FINDINGS:
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**** This amended report supersedes report dated 06/12/2023. It was created to remove identifing information. The additional revision did not change any other aspects of the report and all aspects including the findings remain the same. ***

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Chanel Sanchez and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Chanel Sanchez, Staff 1-6 (S1-6) and Resident 1-7 (R1-7). LPA collected copies of Staff and Resident Rosters. LPA also reviewed R1 admission agreement, physicians report, other pertinent medical records for R1, and sign in/sign out sheets. LPA also conducted a tour of facility which included lobby, random rooms, outside patio area, and common areas. (Continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
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 5
Control Number 28-AS-20230608093038
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: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172
VISIT DATE: 06/12/2023
NARRATIVE
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Investigation revealed the following: Regarding allegation, Wrongful Eviction. It is alleged that R1 is being evicted due to being behind on rent. LPA interviewed Administrator and five staff (S1-S6) and all 6 staff denied that R1 has being given eviction notice. Administrator explained that RI owes back rent and has been asked how R1 would like to get current, and that eviction is a possibility if R1 does not work with facility to catch up but that no eviction notice has been given to R1. R1 collaborated what Administrator stated and confirmed that R1 has not being given an eviction notice. Based on interviews conducted with facility staff, facility residents, and record review there was not enough supportive evidence to concur with the reported allegation.

Regarding allegation, Staff did not safeguard resident's belongings. It is alleged that facility lost R1 dentures, a shirt and pair of pants. LPA interviewed six staff and all six staff denied the allegations. Administrator stated that R1 did not have any dentures when R1 arrived at facility. Administrator stated that R1 refused to inventory R1 belongings. R1 stated that R1 believes that facility R1 was at prior to this forgot to send dentures with R1. R1 stated R1 not sure regarding any clothing is lost. Six of seven residents stated they have never lost any personal items. Based on interviews conducted with facility staff, facility residents, and record review there was not enough supportive evidence to concur with the reported allegation.

Regarding Allegation: Staff do not ensure that residents is provided privacy. It is alleged that other residents are using R1 room as a passageway to get outside. Six of six staff denied the allegation and stated they have never heard of this. R1 could not collaborate the allegation and six of six residents stated they have never had anyone use their room as a passageway or heard of any resident complain of this. Based on interviews conducted with facility staff, facility residents, and record review there was not enough supportive evidence to concur with the reported allegation.

Regarding Allegation, Staff do not ensure that resident is receiving medical attention as needed. It is alleged that R1 is not receiving the medical attention R1 requires. Six of six staff denied the allegations. Administrator stated that resident does see his doctor regularly. Documentation shows that R1 was seen by MD on 02/23/23, 03/08/23, 04/15/23 and 5/13/23. R1 stated that R1 asked Administrator for podiatrist the day R1 arrived and has not yet seen a podiatrist. S3 (nurse) stated that podiatrist comes every two months or on an emergency basis. According to S3, R1 never required emergency podiatrist service and will be seen on June 20th. Administrator stated that podiatrist is scheduled to make visit on June 20th, 2023, and R1 is on the list to be seen. Six of seven residents stated they get all the medical attention they need and have not heard of any resident being denied medical attention. Based on interviews conducted with facility staff, facility residents, and record review there was not enough supportive evidence to concur with the reported allegation.

(continued on 9099C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20230608093038
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: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172
VISIT DATE: 06/12/2023
NARRATIVE
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Regarding Allegation: Staff do not ensure that resident's room is maintained at a comfortable temperature. It is alleged that room is to cold due to door left open by roommate of R1. R1 stated the R1 is comfortable in R1 room and has no complaints about the temperature. Six of six staff denied the allegation. Maintenance man S6 stated that AC units at facility are for 3 rooms and that sometimes the residents of the three rooms cannot agree on a temperature but S6 stated he has not heard of any complaints about being uncomfortable in their rooms. Seven of seven residents could not collaborate the allegations. Based on interviews conducted with facility staff, facility residents, and record review there was not enough supportive evidence to concur with the reported allegation.

Regarding Allegation, Staff do not respond to requests for communication about resident in a timely manner. It is alleged that facility does not return calls when inquiring about a resident. Six of Six staff denied the allegation and stated they return all calls even if they are unable to provide information due to HIPPA laws and that is explained to callers. R1 could not collaborate this allegation. Six of six residents could not collaborate the allegation and have never heard of any issue with callers getting a returned call from the facility. Based on interviews conducted with facility staff, facility residents, and record review there was not enough supportive evidence to concur with the reported allegation.

Although the allegations 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.



Exit interview held. A copy of the report was provided to Administrator Chanel Sanchez.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/08/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230608093038

FACILITY NAME:NORWALK RETIREMENT VILLAFACILITY NUMBER:
198603172
ADMINISTRATOR:CHANEL A. SANCHEZFACILITY TYPE:
740
ADDRESS:11515 FIRESTONE BLVDTELEPHONE:
(562) 379-9200
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:80CENSUS: 67DATE:
06/12/2023
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Chanel A Snachez TIME COMPLETED:
03:59 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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This amended report supercedes report dated 6/12/2023 It was created to correct the finding to Substantiated. NO other aspects were changed.

Regarding allegation: Facility is in disrepair. It is alleged that the sliding door in R1 room does not close. R1 stated they fixed it today and now closes. Maintenance man S6 stated S6 just fixed it. S6 stated that it had been in disrepair for a while now and that the bottom rails of the door were bent and that prevented the door from closing properly. Three of six staff denied the allegation. Three staff stated they had heard that sliding door needed repair. LPA inspected the sliding door in R1 room, and it closed and opened with little to no effort. However the screen door falls of the rail when attempting to close it due to the bottom of the rails being damaged which posed/poses a health and safety hazard to residents in care.

Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Appeal rights were given. A copy of the LIC 9099/LIC 9099C/LIC 9099D was given during the exit interview.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
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 5
Control Number 28-AS-20230608093038
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: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2023
Section Cited
CCR
87303(a)
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87303) a Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met as evidenced by:
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Administrator will have screen door rails repaired or replaced by POC date and send proof to LPA by POC date.
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Room 19A sliding door was in disrepair and did not close properly until today 6/12/2023 and screen door in room 19A does not close properly and requires repair and replacement as it posed/poses a health and safety issue to 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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5