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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 07/02/2021
Date Signed: 07/02/2021 03:03:07 PM

Substantiated


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
02/08/2021 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210208132330
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:
07/02/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eizabeth MartinezTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff did not safeguard residents personal property.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Nicol Wesley and Luis Mora initiated an unannounced subsequent complaint investigation for the allegation listed above and met with Assistant Administrator Elizabeth Martinez to discuss the purpose for todays visit.

Investigation consisted of: While operating as a surge facility, LPA Wesley interviewed Licensee Adam Zenou, Administrator Lisa Pham, Assistant Administrator Elizabeth Martinez, and requested copy of the: staff roster, resident roster and a copy of the client/resident personal property and valuables(LIC 621) for resident #1 to be faxed/emailed to LPA Wesley on or before 02/10/21 by 5pm.

Investigation revealed the following regarding allegation: Facility staff did not safeguard residents personal property. During the interview with Assistant Administrator Elizabeth Martinez , it was discovered that staff were not aware that resident #1's phone was missing, and acknowledged that the resident did have a cell phone
Continued on LIC 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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 3
Control Number 28-AS-20210208132330
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: 07/02/2021
NARRATIVE
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while residing in the facility. The Administrator said they did not recall whether or not resident #1 took the phone with them prior to being transferred to a hospital on 12/25/20, and the hospital records indicated upon intake resident #1 did not have a cellphone with their property. During the investigation it was also discovered by staff that prior to admission resident #1 did not have a cellphone on their property list, when they were transferred to a facility on 01/06/21. Assistant Administrator advised that the licensee was informed that resident #1's cellphone was missing and the licensee agreed to reimbursed the resident so they can purchase another phone(Chase Bank, check number 132 dated 01/14/21).

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Appeal rights were given. A copy of the LIC 9099/LIC 9099C/LIC 9099D was given during the exit interview.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Citations on this Visit Report are Under Appeal!

Control Number 28-AS-20210208132330
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
07/02/2021
Section Cited
CCR
87218(a)(2)
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Theft and Loss. A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed current value and shall be presumed to have made reasonable efforts to
safeguard resident property if there is clear
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The licensee will ensure to help monitor and safeguard the all of the residents property and valuables while in care. The licensee/Administrator will replace residents #1's cellphone ASAP.
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and convincing evidence of efforts to This evidence has not been met as required by: Resident #1's cellphone was last seen at the facility prior to being transported to a hospital on 12/25/20 in which it was not included in the residents personal property, or valuables.
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**This deficiency was corrected on 01/14/2021.**
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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: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3