198603172-3-7-2023-28-AS-TVAO-CPRTGD-20230309134256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 03/03/2023
Date Signed: 03/07/2023 04:57:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/11/2021 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210611101304

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: 76	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Sanchez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are mismanaging residents medication.
Staff are not providing adequate food service.
Staff did not safeguard residents belongings.
Staff did not prevent resident from making inappropriate comments towards another resident.
Staff did not seek medical attention for resident.
Facility phone is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit to deliver findings from previous subsequent complaint visit on 03/02/23, stemming from initial 10-day complaint visit conducted on 06/08/2021, by LPA Wesley and LPA Mora. LPA Ramirez was met by Administrator Chanel Sanchez and explained the purpose of the visit.

The investigation consisted of: An inspection of the interior and exterior physical plant was conducted. Staff (S1-S5) and residents (R1- R4) were interviewed. Resident (R1) was not present and was interviewed telephonically. Resident file documents: [Identification and Emergency Information, Preplacement Appraisal, and Physician's Reports, medication orders, any other pertinent documents that may assist in this investigation were reviewed and obtained. LPA requested and obtained: LIC 500 Personnel Report, and Resident roster.

See LIC 9099-C for continuation.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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-20210611101304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VILLA	FACILITY NUMBER: 198603172
	VISIT DATE: 03/03/2023

NARRATIVE

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Allegation: “Staff are mismanaging residents’ medication.” It is alleged that staff are mismanaging residents’ medications according to residents needs.” Five (5) out of the five (5) Staff (S1 – S5) interviewed, deny this allegation. Three (3) out of the four (4) residents (R2 – R4) interviewed, denied staff mismanaging their medications. LPA reviewed medication orders for R1 however, due to R1 no longer being at the facility, LPA could not verify Medication Administration Record (MAR) from 05/01/2021 through 06/30/2021. At 2:25 pm, LPA Ramirez observed S4 pushing medication cart through facility hallway and stopped at near by resident room to administer medication. LPA observed S4 to be wearing gloves, and a surgical mask while administering medication to resident. A pitcher with a clear liquid was also observed on the medication cart.

Allegation: “Staff are not providing adequate food service.” It is alleged that food is being improperly handled by staff. Five (5) out of the five (5) Staff (S1 – S5) interviewed, deny this allegation. Three (3) out of the four (4) residents (R2 – R4) interviewed, denied staff are not providing adequate food service. LPA Ramirez conducted kitchen tour at 10:45 am while kitchen staff was preparing lunch. Kitchen staff were observed wearing hair nets and gloves while preparing food. LPA Ramirez verified Food Handler Certifications for three (3) of the kitchen staff that were present. At 12:07 pm, LPA Ramirez observed kitchen wearing gloves and hair nets while plating dishes and placing meals on dining cart. LPA observed servers wearing gloves and hair nets while serving meals to residents’ tables.

Allegation: “Staff did not safeguard residents’ belongings.” It is alleged that staff did not safeguard residents’ belongings. Five (5) out of the five (5) Staff (S1 – S5) interviewed, deny this allegation. Three (3) out of the four (4) residents (R2 – R4) interviewed, denied staff did not safeguard residents’ belongings. At 11:37 am, while LPA Ramirez and Administrator Sanchez were conducting tour, LPA overheard R2 telling staff that R2’s hamper was missing from their room. LPA Ramirez observed Administrator Sanchez and another staff, go into R2’s to try and locate the alleged missing hamper. Administrator Sanchez and staff found the hamper in R2’s room. The hamper had been moved to a different area of the room by staff, to clean R2’s room.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210611101304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VILLA	FACILITY NUMBER: 198603172
	VISIT DATE: 03/03/2023

NARRATIVE

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Allegation: “Staff did not prevent resident from making inappropriate comments towards another resident.” It is alleged staff did not prevent resident from making harassing comments towards resident. Five (5) out of the five (5) Staff (S1 – S5) interviewed, deny this allegation. Three (3) out of the four (4) residents (R2 – R4) interviewed, denied staff did not prevent resident from making inappropriate comments towards another resident. Although three (3) out of the four (4) residents deny this allegation, they confirm having hearing and seeing residents say inappropriate comments to each other but, residents (R2 – R4) all confirm staff will immediately redirect involved residents’ and diffuse the situation.

Allegation: “Staff did not seek medical attention for resident.” It is alleged staff did not seek emergency medical attention for resident R5 on or about 06/15/21. Five (5) out of the five (5) Staff (S1 – S5) interviewed, deny this allegation. Three (3) out of the four (4) residents (R2 – R4) interviewed, denied staff did not seek emergency medical attention for resident in care. LPA verified resident R5 Special Incident Report (SIR) and could not find any pertinent documentation that suggests R5 required immediate emergency services on or about 06/15/21.

Allegation: “Facility phone is in disrepair.” It is alleged facility phone is in disrepair and unable to receive voicemails. Five (5) out of the five (5) Staff (S1 – S5) interviewed, deny this allegation. Three (3) out of the four (4) residents (R2 – R4) interviewed, denied facility phone was in disrepair. At 11:11 am, LPA Ramirez observed a telephone located on second floor of facility community room. A second telephone was observed on the first floor of the lobby area. LPA picked up receiver of phones and heard dial tones. LPA tested phones and observed both phones to operable.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC9099 (FAS) - (06/04)

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