<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:46:45 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
02/13/2024 and conducted by Evaluator Tyler Reyes
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240213092437
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: 75DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Francine Reyes Wellness Director TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged residents' medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licesning Program Anaylst (LPA) Tyler Reyes conducted an unannounced complaint investigation visit for the allegation listed above. LPA met Francine Reyes-Wellness Director and the purpose of the visit was discussed.
On 02/16/2024 LPA Wesley conducted an unannounced complaint visit and met with Assistant Elizabeth Martinez. LPA requested a copy of resident roster, staff roster, interviewed staff and residents. Additional 05/03/24 LPA Wesley conducted an unannounced subsequent visit and met with Administrator Rachelle Reves. LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, and reviewed the medication.

***The licensing report created on 05/03/2024 is being superseded by this licensing report dated 08/27/2024. The licensing report is being redelivered due to additional interviews that were conducted and further information that was obtained. The investigation findings will remain the same.***

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
02/13/2024 and conducted by Evaluator Tyler Reyes
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240213092437

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: 75DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Francine Reyes Wellness Director TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide a safe and comfortable environment for residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licesning Program Anaylst (LPA) Tyler Reyes conducted an unannounced complaint investigation visit for the (2) allegations listed above. LPA met Francine Reyes-Wellness Director and the purpose of the visit was discussed.

On 02/16/2024 LPA Wesley conducted an unannounced complaint visit and met with Assistant Elizabeth Martinez. LPA requested a copy of resident roster, staff roster, interviewed staff and residents. Additional 05/03/24 LPA Wesley conducted an unannounced subsequent visit and met with Administrator Rachelle Reves. LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, and reviewed the medication.

***The licensing report created on 05/03/2024 is being superseded by this licensing report dated 08/27/2024. The licensing report is being redelivered due to additional interviews that were conducted and further information that was obtained. The findiings have changed from unsubstainted to substainted.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240213092437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172
VISIT DATE: 08/27/2024
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
26
27
28
29
30
31
32

In regard to the allegation” Staff did not provide a safe and comfortable environment for residents” it is alleged medication is being left unattended within the facility and that med techs are providing residents with medications and not ensuring that the medications have been taken. The investigation consisted of tour of the facility dinning room and a random sample of resident rooms. LPA Reyes examined the dresser and trash cans of Resident #1 (R1) R1-R4, R6-R10, and R12's room. (5) of (8) staff confirmed the allegation. Staff indicated that they have witnessed pills inside the hallways, in resident's rooms, in the dinning room, and on the property outside the facility. (10) of (12) residents could not corroborate the allegation. LPA Reyes toured the dinning room and observed at 12:09 PM Staff #8 (S8) had left the med cart unattended and unlocked for few minutes while outside in the court yard administering resident's medication.When S8 returned from outside S8 apologized and stated they have forgot to lock the cart. LPA Reyes informed S8 it is important the cart remains locked when unattended.

Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.



Exit interviewed conducted with Francine Reyes Wellness Director and a copy of this report was provided with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240213092437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/28/2024
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
87465Incidental Medical Care(h) The following requirements shall apply to medications which are centrally stored(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible ....
1
2
3
4
5
6
7
Administrator will provide LPA Reyes with the following documents in-service training for all staff on medication. Administrator will provide within 24hrs the date for the planned traininig staff and the training materials.

8
9
10
11
12
13
14

Based on observations LPA Reyes toured the dinning room and observed at 12:09 PM Staff #8 (S8) had left the med cart unattended and unlocked for few minutes while outside in the court yard administering resident's medication.This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240213092437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172
VISIT DATE: 08/27/2024
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
26
27
28
29
30
31
32
In regard to the allegation “Staff mismanaged residents' medication” it is alleged residents are not receiving their medication. It is alleged that some residents medications are being left on their dressers, in the dining room tables, or in their trash cans in their rooms. (8) of (8) staff interviewed denied the allegation. Staff indicated the following that they ensure all residents take their medication before assisting another resident with medication. Staff assist residents by providing water and notifying residents when it is time to take medication.(9) of (12) residents denied the allegation. Residents interviewed indicated that staff are efficient in administering medication. Residents state they receive their daily dose of medication. LPA Reyes conducted record review (6) or (6) residents' August 2024 "Physicians Current Orders of Routine Medication" and medication is being given as prescribed by a physician. LPA Reyes observed in dinning room at 12:09 PM staff #8 (S8) member assisting with administering medication to residents.

Based on the interviews conducted, files reviewed, and observations conducted 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 Interviewed conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5