198603172-2-27-2023-28-AS-MVAO-CPHU5J-20230301141650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:54:27 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
02/11/2022 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220211124405

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: 64	DATE:	02/27/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Assistant Administrator- Elizabeth Martinez		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident denied rent refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted subsequent complaint investigation for the allegation listed above. LPA met with Assistant Administrator Elizabeth Martinez and explained the purpose for todays visit.

On 2/17/22, LPA Nicol Wesley conducted the initial investigation. LPA Wesley requested copy of the: staff roster, resident roster, copy of admission agreement, Unusual Incident Report(SIR) for month a January. LPA Wesley interviewed staff and attempted to interview resident #1.

On 2/27/23, the subsequent visit by LPA Calderon consisted the following: LPA Calderon requested copy of the: staff roster, resident roster, Resident #1 (R1) Facesheet, Admission Agreement, Physician Report, Acknowledgement of Discharge Form, Supporting Email Documentation, and check stub issued to R1. LPA Calderon interviewed Assistant Administrator Elizabeth Martiniez, and telephonically interviewed R1 and Financial Representative of R1. (Continuation on 9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220211124405

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: 02/27/2023

NARRATIVE

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Based on the Allegation: Resident denied rent refund. The investigation reveled the following: LPA Calderon conducted interview with staff Assistant Administrator Elizabeth Martinez: interview indicated R1 was issued a check for a pro-rated amount, name on check is R1's payee representative and a refund confirmation via email/verbal was conducted by Norwalk Retirment Villa LLC Staff Consultant Linda Estrada . LPA conducted interview with R1, R1 interview conducted telephonically states Norwalk Villa does not owe a rent refund, and everything is okay. LPA telephone interviewed R1 financial representative stated R1 was issued a refund check by the above facility upon self-discharge. LPA collected, reviewed and observed supportive documentation email/ pay check stub of refund issued to R1's payee represenative by Corporation Nowalk Retirement Villa LLC.

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

An exit interview was conducted and a copy of this report was provided to Assistant Administrator Elizabeth Martinez

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC9099 (FAS) - (06/04)

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