198603172-12-21-2023-28-AS-RORN-CZYQJL-20240130111256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:01:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/15/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231215154209

FACILITY NAME:	NORWALK RETIREMENT VILLA		FACILITY NUMBER:	198603172
ADMINISTRATOR:	CHANEL A. SANCHEZ		FACILITY TYPE:	740
ADDRESS:	11515 FIRESTONE BLVD		TELEPHONE:	(562) 379-9200
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	80	CENSUS: 68	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Chanel Sanchez		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident wandering away from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint visit to investigate the above allegation. LPA met with Administrator Chanel Sanchez and discussed the purpose of today’s visit.
At today's visit Resident and Staff Roster was submitted.
Interview was conducted with Administrator at 12:30 PM.
File was reviewed for Resident R 1 and the following forms were submitted:
Physician's Report, Admission Agreement, and Emergency ID.
Special Incident Report's (SIR's) were submitted.
Documentation from Nowalk Police was submitted dated 12/15/2023 and 12/17/2023.
Interviews were conducted with Staff S 1 and Staff S 2 from 12:45 PM to 130 PM.
Interviews were conducted with Resident's R 2- R 7 from 1:35 PM to 2:15 PM.
In regards to the allegation, Staff did not provide adequate supervision resulting in resident wandering away from facility, based on interviews conducted and information gathered it was revealed on Physician's Report dated 11/15/2023 for Resident R 1 that box is checked yes for able to leave the facility unassisted.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231215154209

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: NORWALK RETIREMENT VILLA	FACILITY NUMBER: 198603172
	VISIT DATE: 12/21/2023

NARRATIVE

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Documentation from Norwalk Police dated 12/15/2023 Report # 023-14437-0453-400 and 12/17/2023 Report # 023-14508-0453-400 are reports that were done by the facility for a missing person's report.
Resident's interviewed all stated that staff do a great job and perform their jobs professionally.
All of the resident's stated that there is no lack of supervision or neglect by staff and they are always on their toes and always on point.
Also stated that there is a sign in and out sheet and staff are at the front desk and can see everyone leaving.
2 of 6 resident's knew of R 1 not coming back, and doesn't think anything neglectful by staff and said there is no way to hold him here because he has the right to leave.
Interviews with staff who stated that R 1 has personal rights to leave facility unassisted and that can't be taken away.
Stated that R 1 has often gone out and returns. Said he is not a wanderer. Said the care staff is up front.
1 staff interviewed stated that R 1 said he had gone overnite to his old house and then to the VA to follow up on his meds. Said that the facility picked him up the following day and had filled out a missing person's report when R 1 did not return.
It should be noted that R 1 was not at the facility at today's visit and is currently in the hospital.

Based on the interviews conducted with staff, clients, review of client files and facility records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation 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.

A copy of this report was given to Chanel Sanchez, during the exit interview.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

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