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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 10/17/2024
Date Signed: 10/17/2024 09:38:32 AM

Substantiated


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: 77DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Administrator Rachelle ReyesTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff mismanaged residents' medication
Staff did not provide a safe and comfortable environment for residents
INVESTIGATION FINDINGS:
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***The licensing report dated 08/27/24 is being superseded by this report dated 10/17/24. The purpose of the report is to include additional information not included in the previous report and to include all required information on the deficient practice statement and plan of correction. In addition, the finding of the allegation of “staff mismanaged residents’ medication” is being changed from unsubstantiated to substantiated. The findings regarding the allegation of “staff failed to provide safe and comfortable environment for residents” will remain substantiated***.

Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced Subsequent Complaint Visit to deliver the new findings for (1) of (2) allegations. LPA met with Administrator Rachelle Reyes and explained the reason for the visit.

**Continued-LIC9099-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: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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 4
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: 10/17/2024
NARRATIVE
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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.

On 08/27/24 LPA Reyes superseded the licensing reported created on 05/03/24. The licensing report was redelivered due to additional interviews that were conducted and further information that was obtained.

The investigation consisted of: On 08/27/24, LPA Reyes conducted interviews with Administrator Rachelle Reyes, Staff #1 (S1- S8), and Residents #1 (R1-R3 and R6-R12). Residents # 4, 5, and 13-15 were not available to be interviewed. LPA Reyes collected copies of Staff and Resident Rosters, Physician’s Order Routine Medication and Physician Report for R1- R11, Exit forms for R13-R15, and Training for S1, S6, and S8.

Regarding the allegations Staff mismanaged residents' medication and Staff did not provide a safe and comfortable environment for residents. It is alleged residents are not receiving their medication. Residents’ medication is being left on dressers, on the dining room tables, or in the resident’s trash cans in their room. In addition, Med Techs are not ensuring the residents are taking their medication. (6) of (8) staff interviewed confirmed the allegation. Staff indicated that medication had been found in hallways, resident’s rooms, and dining room tables. Staff acknowledge that medication found unattended was reported. Staff members have also confirmed awareness of medication being reported and delivered by other staff. Therefore there is evidence that residents at the facility are not receiving their medications as prescribed. (9) of (12) residents could not corroborate the allegation. During a tour of the dining room on 8/27/24 at 12:09 PM LPA Reyes observed a dining room of residents having lunch near a unlocked, unattended, and accessible med cart

**Continued-LIC 9099-C**

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

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 10/17/2024
NARRATIVE
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LPA Reyes observed S8 with the med cart near the kitchen door of the dining room preparing to deliver medications to residents in the courtyard. S8 was then observed by LPA Reyes from exiting the dining room and on the other end of the courtyard with residents. During this time LPA Reyes did not view any other staff monitoring the med cart or present in the dining room. LPA Reyes positioned himself near the med cart while S8 was assisting residents outside in the courtyard. When S8 returned from the courtyard LPA Reyes opened the cart and confirmed with S8 that med cart was unlocked and accessible to residents. S8 apologized and acknowledged they failed to lock the medication cart. LPA Reyes explained to S8 the importance of locking the med cart.

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 Administrator Rachelle 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: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/18/2024
Section Cited
CCR
87465(a)(4)
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87465(a) (4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met evidence by. This pose an immediate health, safety, and risk to persons in care.
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Administrator will ensure staff assist residents with self- administered medication as needed by verifying medication is taken by resident before assisting another resident. The administrator will conduct in-service training, provide course materials, and attendance sheets with staff signatures to licensee by POC Due Date.
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Based on interviews conducted by LPA Reyes (6) of (8) staff confirmed they have observed medication in various areas of the facility on the floor and counters, including the hallways, resident rooms, and the dining room. The staff have stated they have either witnessed medication pills left unattended or had been informed by staff of such incidents.
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Request Denied
Type A
10/18/2024
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental 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 for the supervision of the centrally stored medication.

This requirement is not met evidence by:

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Administrator will ensure centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. The administrator will conduct in-service training, provide course materials, and attendance sheets with staff signatures to licensee by POC Due Date.
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Based on interviews conducted and observations by LPA Reyes, (6) of (8) staff confirmed they have observed medication in various areas of the facility on the floor and counters, including the hallways, resident rooms, and the dining room. Additionally, during the visit on (insert date) LPA Reyes observed medication cart being left unlocked, unattended, and accessible to all residents in the dining room. S8 admitted to LPA Reyes of leaving the med cart in dining room unlocked. This poses an immediate health, safety, and risk 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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4