<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:57:02 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
01/12/2022 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220112084432
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: 48DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Assistant Administrator, Elizabeth MartinezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not assist resident with self-administration medication.

Staff do not repond to resident's call for assistance.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2: Elizabeth Martinez). LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation(s). An initial 10-Day visit was conducted by LPA Nicol Wesley on 01/13/22 who interviewed staff and resident #1. LPA/RA Ceniceros interviewed (between 1:00 p.m - 1:45 p.m.) three (3) staff members and three (3) residents in care. LPA/RA reviewed (between 1:45 p.m. – 2:00 p.m.) the requested documents: Face Sheet (dated 12/31/21), Emergency I.D. & Information (dated 01/13/22), Physician’s Report (12/21/21), Medication Administrator Record (January 2022), Acknowledgement of Discharge (dated 01/13/22) for Resident #1 (R1); facility's staff roster and resident resident.

Regarding Allegation #1: this investigation revealed based on interviews conducted corroborated that the Med Techs administer the residents' medications in a timely manner for breakfast, lunch, dinner and/or
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
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-20220112084432
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: 10/27/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
bedtime. Facility staff have not received complaints from residents or responsible person/family member that the Med Techs are not assisting residents in administering their medication(s). LPA/RA toured the medication room and observed the medications to be in a secured, locked cart. LPA/RA observed the medication administration record (MAR) to be documented under QUICK MAR system once medications are administered to the residents by the Med Techs. A review of R1's physician's report documented under: Medication Management that the resident is able to administer own prescription medications, able to administer own PRN medications, and able to store own medications. A review of (former) Resident #1's medication administration record for the month of January 2022 documented that the resident was administered the medication (Abilify) once daily at 8:00 a.m. from 01/01/22 thru 01/16/22; resident was out of the facility 01/14/22 to 01/16/22 and did not return to the facility. After three (3) days, facility will remove the resident from the QUICK MAR system - just in case the resident decides to return. In this case, Resident #1 moved out on 01/13/22; and, the pharmacy provided a service to destruct the medication(s).

Based on the evidence gathered and interviews conducted and records reviewed, 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 of MEDICATIONS: Staff do not assist resident with self-administration medication is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted corroborated that the Receptionist has answered calls made by the residents whenever they've called the front desk from their room phones or personal cell phones. Facility staff have not received complaints from residents or responsible person/family member that the staff member manning the front Receptionist desk does not answer residents' incoming calls in a timely manner. LPA/RA observed the front desk answering incoming calls during this visit and called the facility directly at (562) 379-2000; and, the call was answered within two (2) rings.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff do not respond to resident's call for assistance found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Assistant Administrator, Elizabeth Martinez

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2