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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603172
Report Date: 12/06/2022
Date Signed: 12/06/2022 03:07:23 PM

Document Has Been Signed on 12/06/2022 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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: 60DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Lisa PhamTIME COMPLETED:
03:19 PM
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
Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced site visit for the Required - 1 Year inspection focusing on infection control. Upon arriving at the facility, LPA met with Administrator Lisa Pham and assistant administrator Elizabeth Martinez and stated the purpose of the visit.. LPA conducted inspection using Infection Control Domain Tool. Last fire drill was September 16, 2022. Administrator certificate expires 03/01/24

Structure:
The facility property is a two story commercial building, licensed to serve 80 non-ambulatory residents ages 60 and above, of which 10 can be bedridden. The designated rooms for bedridden residents are rooms 1, 3, 5, 7, and 9, The facility has an approved hospice waiver for 30 residents. There are a total of 40 resident rooms.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPAs was screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has two designated isolation room.
· 7 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Client rooms were equipped with alcohol-based hand sanitizer.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.

· A posted Emergency Disaster Plan was posted but was at facility.


· PPEs were observed.
· Staff and resident files were not reviewed during today's visit.
·
Deficiencies cited per Title 22 Health and safety code, See 809D for details.
·
Exit interview was conducted with Assistant Administrator Lisa Pham. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/06/2022 03:07 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/06/2022 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Room #33 water in the tub measured 90 degrees F and water in room 11 tub measured 123.5 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
1
2
3
4
Administrator adjusted water temperature during visit and will continue to monitor water temperature to make sure it is within regulatory range. ****No further action is required****
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/06/2022 03:07 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/06/2022 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Room 13 towel rack was in need of repair as it was off the wall which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2022
Plan of Correction
1
2
3
4
Administrator will repair towel rack and send proof of correction to LPA by POC date.
****Towel rack was repaired during visit and not further action is required****
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. One door screen was in need of repair which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 12/13/2022
Plan of Correction
1
2
3
4
Administrator will repair torn screen and send LPA proof by POC date.

*****Screen was repaired during visit and not further action is required****
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3