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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 07/25/2022
Date Signed: 07/25/2022 12:43:16 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
07/19/2022 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20220719124719
FACILITY NAME:NORWALK RETIREMENT VILLAFACILITY NUMBER:
198603172
ADMINISTRATOR:RFACILITY TYPE:
740
ADDRESS:11515 FIRESTONE BLVDTELEPHONE:
(562) 379-9200
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:80CENSUS: 34DATE:
07/25/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Lisa Pham TIME COMPLETED:
12:57 PM
ALLEGATION(S):
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Facility staff did not ensure that resident was properly dressed at night..
Staff member was verbally abusive toward resident.
Facility does not provide a safe environment for resident.
INVESTIGATION FINDINGS:
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On 7/25/22 at 9:00 A.M., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Lisa Pham (Administrator) and Elizabeth Martinez (Assistant Administrator). LPA explained the purpose of the visit and toured the facility with Assistant Administrator.

During today’s visit LPA toured the facility, reviewed files of four residents (R1- R4) and obtained resident/ staff roster, R1 face sheet, physician report and admission agreement. LPA interviewed four residents (R1- R5), Administrator and three staff (S1- S3).

The investigation reveals the following: Regarding "Facility staff did not ensure that resident was properly dressed at night" it was alleged that staff did not dress S1 for the night.
Report conintued on 9099c
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
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-20220719124719
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: 07/25/2022
NARRATIVE
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During the investigation LPA conducted a walk through with assistant administrator and did not observed inappropriately dressed residents. File review revealed S1 need assistance with getting dressed. S1 confirmed facility staff has always made sure they were properly dressed and cleaned at night. 2/5 residents stated they do not need assistance getting dressed and have not heard residents complained about not receiving staff assistance at night. 3/5 residents stated they do need assistance getting dressed and staff has always ensured they were properly dressed for bed. Administrator confirmed staff has always ensured residents are dressed appropriately. Administrator also confirmed that the facility has not received complaints from residents being left inappropriately dressed at night. 3/3 staff stated residents are always dressed appropriately.

The investigation reveals the following: Regarding " Staff member was verbally abusive toward resident." it was alleged that a staff member lied on a resident. 4/5 residents stated that staff has never verbally abuse residents and has never witness other residents being verbally abused by staff. 1/4 residents stated staff lied in an incident, but they are getting along now. Administrator confirmed they have not received complaints from residents stating staff verbally abused them, but if they did, they would do an internal investigation. 3/3 staff stated they have not witness staff verbally abusing residents.

The investigation reveals the following: Regarding " Facility does not provide a safe environment for resident”. It is alleged that R1 do not feel safe at the facility following the incident where staff lied. 4/5 residents stated that they feel safe at the facility. 1/4 resident stated facility has to many glass windows, which leads them to feel unsafe. Administrator confirmed facility has security personnel and conducts wellness checks. 3/3 staff feel the facility provides safe environment because of security staff, wellness checks, and staff dedication.

Based on LPA's interviews, observation and file review, the investigation revealed: 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 conducted with Administrator Lisa Pham and Assistant Administrator Elizabeth Martinez, A copy of this record provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2