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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:23:26 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 Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20211229160311
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: 26DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Elizabeth Martinez, Assiistant Administrator TIME COMPLETED:
03:23 PM
ALLEGATION(S):
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9
Facility has insufficient staffing to meet the residents' needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent 10 day complaint investigation for the allegations listed above. LPA met with Assistant Administrator Elizabeth Martinez and Administrator Lisa Pham and discussed the purpose for today’s visit.
The investigation consisted of the following: LPA interviewed residents #1-#4 (S1-S4) between 10:39 am-12:14pm, LPA Toured the physical plant with Assistant Administrator and found no health or safety concerns. LPA Interviewed Administrator and Assistant Administrator from 12:14-12:48pm. LPA also reviewed the following documents: staff roster, resident roster, LPA interviewed Staff #1 -Staff #4 (SI-S4) from 1:37 - 2:58pm The Investigation revealed the following:
In regard to the allegation, "Facility has insufficient staffing to meet the residents' need" Administrator and Assistant Administrator denied the allegations and (4) of (4) staff interviewed denied the allegations. The staff interview stated that all residents’ needs are being met daily. (4) of (4) residents could not corroborate the allegation. Review of staff roster shows that facility keeps enough staff per shift.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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 2
Control Number 28-AS-20211229160311
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: 03/02/2022
NARRATIVE
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 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 allegation is UNSUBSTANTIATED
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2