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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 03:59:55 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
02/24/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220224103531
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:
10:55 AM
MET WITH:Lisa Pham TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff did not provide a safe environment.
Resident is being over medicated.
Resident not being provided adequate hygiene services.
Staff did not safeguard resident personal information.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint viist to investigate the above allegations. Upon arrival, LPA met with Assistant Administrator Elizabeth Martinez and discused the purpose of the visit. Shortly after, the administrator Lisa Pham arrived.

The investigation consisted of the following: On today's visit, LPA interviewed four residents (R2-R5) , assistant adminstrator, administrator and three staff (S1-S3). The following documents were collected which included: staff and resident roster and documents for Resident#1 (R1) - face sheet, physicaian report, Medication Adminsitration Record (MARs), Admission agreement and Pre-Placmenet. LPA also toured R1's room.

The investigation revealed of the following: Allegation#1 "Faciltiy staff did not provide a safe environment." LPA interviewed four residents and all reported they feel safe living in the facility.
(See LIC 9099C 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: 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-20220224103531
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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 They never saw any strangers came or walked around the facility. No other resident would walk into their rooms. LPA interviewed staff and staff reported the front door from outside is always locked and visitor has to ring the bell and staff would open the door for them for signing in or screening for COVID-19 procedure. Staff also reported they never saw any strangers walked around from the facility. LPA also toured R1's room, no one would be able to come in from the patio door unless the resident open the patio door and the screen door.

Allegation#2 "Resident is being over medicated." LPA interviewed four residents and all reported staff always give them correct medication and dosage and on the right time too. They never messed up their medication. They also stated that no residents ever over medicated in the facility. LPA also interviewed staff and reported they always follow doctor's order for resident medication, they would only give resident medication which doctor prescribed or approved and its never happened for a resident in the facility got over medicated. LPA also reviewed the residents' medication and they are accurate and updated.

Allegation#3 "Resident not being provided adequate hygiene services." LPA interviewed four residents and all reported staff are taking good care of them. They always get shower on schedule weekly. And residents reported they have never seen any residents smelled bad or being dirty in the facility. LPA interviewed staff and reported they usually shower residents twice a week or as needed. Staff also reported R1 is independent in all his Activities of Daily Living (ADLs) including showering, dressing and grooming..etc. Its R1's choice not to shower daily or change his clothes. Staff did encourage R1 but they cannot force R1 because it's R1's personal right.

Allegation#4 "Staff did not safeguard resident personal information. " LPA interviewed four residents and all reported they never lost anything in the facility and it's safe to live in the facility. Staff are taking good care of them, LPA interviewed staff and no one reported they lost or got stolen any personal information in the facility. Staff reported they would not give out any personal information to anyone unless they got the verbal permission or consent from the residents who are self responsible. If they are not self responsible, they would contact family or conservator and follow the protocol.

Based on the interviews conducted, documents reviewed and observation, 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 Administrator- Lisa Pham.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
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