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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 01/31/2023
Date Signed: 01/31/2023 02:46:04 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
01/26/2023 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230126120043
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: 71DATE:
01/31/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Chanel Sanchez (Executive Director)TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff did not ensure that resident received their dialysis treatment while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Chanel Sanchez (Executive Director) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Resident rosters, hospital records, shift records and physician's order report. LPA interviewed Staff #1, #2 in the conference room, interviewed Staff #3 in the medication room and interviewed Residents #1 to #7 in various locations of the facility.

In regards to the allegation: Facility staff did not ensure that resident received their dialysis treatment while in care. Interviews with Staff and Resident indicate Resident #1 refused to attend dialysis treatments on numerous occasions. Transportation service is automatically scheduled by the dialysis center. Record review indicate refusals are documented. Facility Staff notified the dialysis center and Resident #1's doctor after each refusal. Interviews with 6 of 7 Residents indicate they are receiving medical assistance. Continue to LIC9099C......
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
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-20230126120043
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: 01/31/2023
NARRATIVE
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Based on LPA's interviews and record review, the investigation revealed: 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 is unsubstantiated.

Exit interview conducted with Chanel Sanchez and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2