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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603172
Report Date: 06/18/2021
Date Signed: 06/18/2021 04:27:24 PM

Document Has Been Signed on 06/18/2021 04:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAFACILITY NUMBER:
198603172
ADMINISTRATOR:PHAM, LISAFACILITY TYPE:
740
ADDRESS:11515 FIRESTONE BLVDTELEPHONE:
(310) 857-8218
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 80CENSUS: 7DATE:
06/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Jennifer Salazar and Cynthia FloresTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nicol Wesley and Luis Mora conducted a case management initiated a complaint investigation for the allegations listed above and met with conducted with staff Jennifer Salazar.

During todays visit, LPAs were attempting to completed an initial 10 day complaint visit complaint control #28-AS-20200220130538 and observed the following deficiencies noted on the attached LIC 809D

The following deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division (6) and Chapter (8).

Appeal rights given.

Exit interview conducted.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2021 04:27 PM - It Cannot Be Edited


Created By: Nicol Wesley On 06/18/2021 at 03:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/19/2021
Section Cited
CCR
87465(h)(1)(C)

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Incidental Medical and Dental Care Services. Medications shall be centrally stored if, because of the physical arrangements in the facility and the conditions of other persons in the facility, the medications are determined to be a safety hazard to other residents. This requirement was not met as evidence by:
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The Administrator and staff will ensure that all prescribed medication to residents are centrally stored and locked at all times.

Cleared at the time of visit.
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LPAs Wesley and Mora both observed 3 clear labeled boxes of prepared medication(am, noon, pm) for residents in the unlocked conference room located by the facility entrance across from what was identified as the medication room.
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Deficiency Dismissed
Type B
06/25/2021
Section Cited
CCR87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not med at evidence by: LPA's Wesley and Mora observed the facility to be in need of
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The Administrator will correct the items by POC date 06/25/2021.
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cleaning. LPA's observed a food tray with left over food on the dining table, room #11 to be filthy and in need of a thorough cleaning, TV room in room #5 has not been operable for days, the facility courtyard to require lawn service/cleaning to remove old refrigerator/debris, and the facility to place business name on markee/building.
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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.
SUPERVISOR'S NAME:Rebecca Orendain
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2021


LIC809 (FAS) - (06/04)
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