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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 01/05/2022
Date Signed: 01/05/2022 03:48:51 PM

Unsubstantiated


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
12/29/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211229154455
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: 27DATE:
01/05/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cynthia Flores TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff prevents resident from having access to wheelchair while in care.
Resident's diapering needs are not being met.
Resident is not treated with dignity or respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an unanncounced complaint visit to address the above allegations. LPA met with Corporate Assitant Cynthia Flores and explained the purpose of the visit and she also assisted LPA with the visit.

The investigation consisted of the following: LPA interviewed assistant administrator and four staff (S1-S4), four residents (R2-R5) and obtained documents included resdient rosters, staff rosters and copy of Resident#1 (R1) face sheet, preplacement appraisal information and physician report.

The investigation revealed of the following: Allegation#1 "Staff prevents resident from having access to wheelchair while in care." LPA interviewed four residents and all reported that they can move their wheelchair all around the facility. They do have any restrictions on that. LPA interviewed staff and all denied the allegation and reported the residents can even bring the wheelchair back to their room and bedside.
(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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
Control Number 28-AS-20211229154455
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: 01/05/2022
NARRATIVE
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Allegation#2 "Resident's diapering needs are not being met. " LPA interviewed residents and denied the allegation and reported it usually does not take long for staff to assist with changing diapers, only once a while, it takes about 20 minutes. LPA interviewed staff and reported they never got any complaints from residents about issues with diaper changing. Staff stated that they usually assist with residents' diaper changing every two hours or as needed and most of the residents, they are able to express their needs for diaper changing.

Allegation#3 "Resident is not treated with dignity or respect. " LPA interviewed four residents and reported staff are nice and wonderful in the facility. Staff never being disrespect or treated them without dignity. LPA interviewed staff and denied the allegation and reported all the staff are nice and they are not tolerated any staff being disrespectful to the residents.

Based on the interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. The copy of the report and appeal right was provided to Corporate Assistant-Cynthia Flores.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/29/2021 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20211229154455

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: 27DATE:
01/05/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cynthia Flores TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
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9
Resident's showering needs are not being met.
INVESTIGATION FINDINGS:
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5
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11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted an unanncounced complaint visit to address the above allegations. LPA met with Corporate Assitant Flores and explained the purpose of the visit and she also assisted LPA with the visit.

The investigation consisted of the following: LPA interviewed assistant administrator and four staff (S1-S4), four residents (R2-R5) and obtained documents included resdient rosters, staff rosters and copy of Resident#1 (R1) face sheet, preplacement appraisal information and physician report.

The investigation revelaed of the following: "Resident's showering needs are not being met." LPA interviewed residents and stated they need assistance with showering but staff only watched them doing it without assisting. Resident also reported sometimes staff would get mad at them if the showers takes too long. Therefore residents reported their showering needs are not met.
(See LIC9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20211229154455
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: 01/05/2022
NARRATIVE
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Based on the interviews were conducted, the preponderance of evidences standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC 9099D.

Exit interview conducted and a copy of the report and appeal right was provided to Corporate Assistant- Cynthia Flores.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20211229154455
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: 01/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/18/2022
Section Cited
CCR
87459(a)(1)(B)
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87459 Functional Capabilities (a)The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living (1)Bathing including need for assistnace (B) In bathing one or more parts of the body
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The administrator will ensure the residents's showering needs are being met by reassessing them and determine their ability. The administrator will send LPA a letter and how to ensure the residents' showering needs are able to meet in the facility.
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The requirement is not met as evidenced by
Based on interviews by residents and reported their showering needs were not met due to staff would get mad when they take too long or staff only watched them without providing any assistance.
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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: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5