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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603172
Report Date: 12/23/2021
Date Signed: 02/03/2023 03:32:41 PM

Document Has Been Signed on 02/03/2023 03:32 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: 28DATE:
12/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elizabeth Martinez-assistant administratorTIME COMPLETED:
03:40 PM
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12/23/2021 12:30 p.m. Licensing Program Analyst (LPA) Nina Galarza conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with assistant administrator Elizabeth Martinez and stated the purpose of the visit. LPA later met with Administrator Lisa Pham and stated the purpose of the visit. LPA conducted inspection using Infection Control Domain Tool.

The facility property is a two story commercial building, licensed to serve 80 non-ambulatory residents ages 60 and above, of which 10 can be bedridden. The designated rooms for bedridden residents are rooms 1, 3, 5, 7, and 9. The facility has an approved hospice waiver for 30 residents. There are a total of 40 resident rooms. The facility phone number is 562 379 9200.

LPA toured facility with assistant administrator and S1. On the 1st floor LPA observed: medication room, conference room, 3 common restrooms, office, lounge/TV room, dining room(seating for 55), kitchen with pantry, outside patio area, janitor supply room and 20 resident bedrooms(including the one's designated for bedridden residents). On the 2nd floor LPA observed the laundry room, 4 common restrooms, activity room w/ break room, fitness room, telephone room, janitor supply room, and 20 resident bedrooms. LPA toured a random selection of resident rooms. Resident rooms were furnished appropriately. The bathrooms were observed to be clean and operational w/grab bars. The resident rooms have a signal system located by the resident bed. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility and met Title 22 Regulation guidelines.

CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/23/2021
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The kitchen, food supply and emergency food and water supply were observed. There was a sufficient amount of perishable and non-perishable food supplies. No pesticides or poisons were stored in the food areas.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA reviewed resident medications records and stored medication. All medications were properly labeled and administered as directed by the physician.

The fire extinguishers were observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational.

An outdoor shaded area is available in the outside patio area. There was no pool or bodies of standing water observed in the exterior of the facility property. Exits and passageways were free of obstructions.

Per the California Code of Regulations, Title 22 no deficiencies observed. Exit interview held, copy of report and appeal rights provided.




SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC809 (FAS) - (06/04)
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