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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603172
Report Date: 03/24/2022
Date Signed: 03/25/2022 01:46:15 PM

Document Has Been Signed on 03/25/2022 01:46 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: 31DATE:
03/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:05 PM
MET WITH:Elizabeth MartinezTIME COMPLETED:
06:10 PM
NARRATIVE
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 LPA Nicol Wesley conducted a Case Management inspection, after completing an unannounced initial 10 day complaint investigation at the facility(Complaint Control #28-AS-20220318145550). LPA Wesley met Assistant Administrator Elizabeth Martinez.and Licensee Adam Zenou.

During todays visit, LPA Wesley observed there to be an exterior painting project taking place. During the interview with the Assistant Administrator Martinez and Licensee Zenou, LPA Wesley was informed that the painting project has been taking place since March 4th 2022. The Facility Licensee/Administrator did not notify Community Care Licensing Division(CCLD) that they were planning to complete a painting project for the month of March 2022.

The following deficiency is cited per California Code of Regulations, Title 22, Division 6 and Chapter 8 on the attached LIC 809D. Appeal rights were given along with a copy of this report during the exit interview.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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Document Has Been Signed on 03/25/2022 01:46 PM - It Cannot Be Edited


Created By: Nicol Wesley On 03/24/2022 at 05:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/24/2022
Section Cited
CCR
87203

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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. During todays visit, LPA Wesley observed all the facility windows on the 1st and 2nd level, all of the sliding glass exit doors in all of the
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The facility Licensee will review the regulations and avoid obstructing the windows and exit doors while the residents are in care which can pose a health and safety issue.
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residents rooms and the emergency exit doors by rooms 19 and 20, the TV room on the southwest side of the facility near Firestone Blvd near the residents rooms were covered in masking and tape which prohibits exiting and entering. This poses a health and safety isssue for the residents in care.
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** Corrected at the time of visit**

Licensee Adam Zenou had all of the taping, masking and plastic coverings removed from all of the residents sliding glass doors, exit doors, and emergency exit doors at the time of visit.

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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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