198603172-11-1-2022-28-AS-TVAO-CLEP45-20221122095832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 11/01/2022
Date Signed: 11/01/2022 10:31:51 AM

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 VILLA		FACILITY NUMBER:	198603172
ADMINISTRATOR:	PHAM, LISA		FACILITY TYPE:	740
ADDRESS:	11515 FIRESTONE BLVD		TELEPHONE:	(310) 857-8218
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	80	CENSUS: 48	DATE:	11/01/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cynthia Flores - Corporate Board Member		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not adhere to Admissions Agreement

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst(s) (LPA) Mary Flores and Kimberly Ramirez conducted an unannounced complaint investigation visit at the facility regarding the above allegation(s). LPA Flores met with Alize Solar Med Tech and explained the reason for the visit. Corporate Board Member Cynthia Flores arrived 15 minutes after.

The investigation consisted of the following: On 5/10/22 LPA Flores conducted a complaint investigation visit and 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. On 11/1/22 LPAs conducted a subsequent visit to deliver findings.
(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: 10/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

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-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: 11/01/2022

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

The investigation revealed the following: Regarding allegation: Facility does not adhere to Admissions Agreement. It is alleged facility increased rent without a 60 notice prior to increasing rent, the facility began charging $1099.00 per month, as of January 1, 2022, the facility raised resident's rent to $1234.00 per month. Interviews with residents revealed 2 out 4 residents stated rent was increased within the last year to about $1200 per month without notice. 1 out of 4 residents stated rent has not been increased and is new to facility, and 1 out of 4 residents stated to not know about admissions agreement or increases. Interviews with staff revealed 1 out of 4 staff stated rent increased written notices were provided to the residents that applied on December 14, 2021 due to cost of living increase of five percent and according to Supplemental Security Income (SSI). 3 out of 4 staff interview were not familiar with residents admissions agreement and have not heard of residents complaining of rate increased. Documents reviewed revealed the following 3 out of 4 SSI recipient residents received a written letter dated 12/13/21 of rate increase as of January 1st, 2022. Admissions agreement for R4 was signed on 4/6/21 notes total monthly fees for basic services fee to be $1099.37. R4 initialed a 3% rate increase history: January 2020 rate increase addendum noted on 4/6/21.

Based on interviews conducted with staff, residents and documents reviewed, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be UNSUBSTANTIATED.

Exit interview was conducted with Lisa Pham 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: 10/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2