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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:28:19 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
11/21/2022 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20221121101152
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: 49DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Elizabeth Martinez, Administrator Assistant
Lisa Pham, Administrator
TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not providing residents with adequate food service.
Staff do not treat residents with dignity.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted unannounced 10-day complaint investigation for the allegations listed above. During today’s visit, LPA met with and explained the purpose of today's visit to Administrator assistant, Elizabeth Martinez. At the end of the visit, LPA met with Administrator, Lisa Pham.

Investigation consisted of the following: interviews of Staff from Staff #1 through Staff #5; interviews of residents from resident #1 through resident #7; facility record reviews, and a facility tour. LPA obtained copies of staff and resident rosters; and resident files for resident #1 (R1) with relevant information.

The investigation revealed the following:
In regard to allegation "staff are not providing residents with adequate food service", it was alleged that facility was not providing the 2nd round of food to resident#1 when resident requested more food.
(-continued in LIC 9099 C-)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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-20221121101152
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: 11/29/2022
NARRATIVE
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Six (6) out of seven (7) interviewed residents indicated that they were able to get a 2nd round of food when requested. The quality of food was acceptable to residents. One (1) out of seven (7) interviewed residents stated resident was unable to get 2nd round of food sometimes. All staff interviewed were denied the allegation. Staff interviews revealed they made and prepared food based on residents' needs and facility's certified dietitian's menu. During lunch time, LPA observed that residents were able to get a second round of food per their requests. Facility's food supplies were sufficient. Per record review, facility had weekly menu and alternate food selections. The facility had alternative options for residents if they do not like what was being served for the day. Based on records reviewed and interviews conducted, the facility would provide 2nd round of food to residents when requested. Therefore, food services provided at the facility was adequate.

In regard to allegation "staff do not treat residents with dignity", it was alleged that staff laughed at resident#1 when requesting 2nd round of food. Six (6) out of seven (7) interviewed residents indicated that facility staff treated residents nicely, of which one resident stated resident loved the staff's services. One (1) out of seven (7) interviewed residents stated staff did not treat resident with respect. All staff interviewed denied the allegation. LPA observed that staff were nice to residents and talked to residents with respect. Therefore, the investigation showed staff treat residents with respect.

Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.

An exit interview was conducted with Administrator, Lisa Pham. A hard copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
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