198603172-8-25-2023-28-AS-RORN-D3ATA9-20240312143304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 08/25/2023
Date Signed: 08/25/2023 02:45:29 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
04/18/2023 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230418144527

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: 72	DATE:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Chanel Sanchez (Administrator)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff does not ensure food is of good quality.
Facility does not have a posted legible emergency evacuation plan.
Facility does not ensure monthly fire drills are conducted.
Facility does not ensure residents have planned activities.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long made an unannounced complaint visit at the facility. Upon arrival, LPA met with Administrator Chanel Sanchez and explained the purpose of the visit.

During the initial visit conducted on 04/19/23, LPA Villalobos toured the physical plant with the administrator including, but not limited to the following: the interior and exterior of the facility. LPA did not observe any path obstructions or health and safety hazards. Sufficient food supply was observed and all toxins and sharps were observed to be stored and locked away properly, inaccessible to residents in care. LPA requested and obtained a copy of the staff and resident roster as well as copies of documents from residents #1-#4 (R1-R4) file. No immediate health and/or safety concerns were noted during the visit.

During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters, food menu, emergency evacuation plan, fire drill log, and activity calendar. LPA also toured the facility with Staff #1, interview Staff #1 in the conference room and interviewed Residents #3 to #9 (R3-R9) in the conference room. Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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-20230418144527

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: 08/25/2023

NARRATIVE

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Regarding allegation: Staff does not ensure food is of good quality. LPA toured the kitchen and reviewed the food menu and observed foods to be of good quality. Interview with Staff #1 indicate food is of good quality. Interviews with 7 of 7 Residents also indicate food is of good quality.

Regarding allegation: Facility does not have a posted legible emergency evacuation plan. LPA reviewed a legible copy of the emergency evacuation plan posted on the lobby wall. Interview with Staff #1 indicate the emergency evacuation plan has been posted since the facility began operations. Interviews with 7 of 7 Resident indicate they are aware of an emergency evacuation plan which is legible and where it is posted.

Regarding allegation: Facility does not ensure monthly fire drills are conducted. LPA reviewed copies of scheduled fire drills dated 04/20/23 and 01/19/23 and observed fire drills are conducted every 3 months which is required by department regulations. Interview with Staff #1 indicate fire drills are conducted every 3 months. Interviews with 7 of 7 Residents also indicate fire drills are conducted.

Regarding allegation: Facility does not ensure residents have planned activities. LPA toured the facility and observed the activities calendar posted on the second floor. Interview with Staff #1 indicate Residents have planned activities. Interviews with 7 of 7 Resident also indicate planned activities are provided.

Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is 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 conducted with Chanel Sanchez (Administrator) and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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