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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 10/31/2022
Date Signed: 10/31/2022 03:44:05 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
10/25/2022 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221025093815
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: 48DATE:
10/31/2022
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Elizabeth Martinez TIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff did not provide resident with admissions agreement when requested.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an initial complaint visit regarding the allegations above. LPA met with Assistant Administrator Elizabeth Martinez and the purpose of the visit was discussed.

On todays visit LPA toured the physical plant. LPA reviewed and collected copies of files from resident #1's (R1) file. LPA interviewed residents #1-#5 (R1-R5) and staff #1-#4 (S1-S4) during todays visit. The investigation revealed the following:

In regards to the allegation "Staff did not provide resident with admissions agreement when requested." it was alleged that R1 requested a copy of their admissions agreement and explanation for how monthly rent is calculated but did not receive it. (4) of (4) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
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-20221025093815
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: 10/31/2022
NARRATIVE
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Interviews show that R1 was provided a copy of the admissions agreement once signed and was given an explanation of the price set by the admissions agreement. Staff interviewed do not confirm that R1 requested further copies or explanations after moving into the facility. LPA was not provided with documentation or proof that R1 requested the admissions agreement from the facility at any time. Based on interviews and observations, 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 this allegation is unsubstantiated.

Exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2