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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:31:16 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
05/03/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220503160955
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: 30DATE:
05/10/2022
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Elizabeth Martinez - Assistant Administrator TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility does not provide hygiene items for residents
Facility does not maintain testing equipment for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit at the facility regarding the above allegation(s). LPA Flores met with Angelica Amador Activity Director and explained the reason for the visit. Assistant administrator Elizabeth Martinez arrived 15 minutes later.

The investigation consisted of the following: LPA Flores requested a resident/staff roster. LPA conducted interviews with resident #1(R1), #2(R2), #3(R3), #4(R4), staff #1(S1), #2(S2),#3(S3)#4(S4). LPA requested copies of admission's agreement, face sheets, physician's reports, and notices provided to residents for R1,R2,R3,R4. LPA conducted a tour of supplies storages in first and second floor and medication room.

The investigation revealed the following: Regarding allegation: Facility does not provide hygiene items for residents. It is alleged the facility does not provide residents with razors. 4 out of 4 residents stated to receive basic hygiene supplies such as shampoo, soap, toilet paper. 2 out of 4 residents interviewed stated to not received razors at the facility. (CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
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 4
Control Number 28-AS-20220503160955
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: 05/10/2022
NARRATIVE
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4 out of 4 staff interviewed stated residents are provided basic hygiene products such as shampoo, body wash, soap, toilet paper, toothpaste, toothbrushes, and razors are provided to those residents that are independent upon request but residents are notify that razors must be keep under lock to avoid residents getting hurt. Admission agreement reviewed by LPA revealed facility is to provide basic hygiene items such as general use soap and toilet paper and resident or responsible party is responsible for "personal toilet articles, i.e. toothpaste, kleenex, mouthwash, shampoo, etc." LPA observed facility maintained some body wash, shampoo, toothbrushes and sufficient toilet paper and hand soap in storage areas. Assistant administrator staed there is grooming services provided to male residents.

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.


Regarding allegation: Facility does not maintain testing equipment for residents. It is alleged facility does not maintain a blood pressure, or blood sugar testing machines for residents to check their blood pressures and blood sugar levels. Interviews with residents revealed, 3 out 4 residents stated facility has equipment to check blood pressure or sugar levels. 1 out of 4 residents stated facility does not have working equipment as facility may run out of batteries. Interviews with staff revealed, 4 out of 4 staff stated facility has working equipment for blood pressure or blood sugar testing for residents that require it. Assistant administrator stated that the facility does not provide blood pressure checks to all residents as the facility does not provided skill nursing level of care. However, does maintain equipment for residents that need services. LPA observed facility had sufficient blood sugar equipment for residents with prescription and two blood pressure machines available and in working condition at the time of the visit.

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.


Exit interview was conducted with Elizabeth Martinez Assistant Administrator and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4