198603172-4-7-2023-28-AS-TVAO-CRYTX8-20230519150639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 04/07/2023
Date Signed: 04/07/2023 11:34:19 AM

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
03/30/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230330100849

FACILITY NAME:	NORWALK RETIREMENT VILLA		FACILITY NUMBER:	198603172
ADMINISTRATOR:	CHANEL A. SANCHEZ		FACILITY TYPE:	740
ADDRESS:	11515 FIRESTONE BLVD		TELEPHONE:	(562) 379-9200
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	80	CENSUS: 69	DATE:	04/07/2023
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Elizabeth Martinez - Assistant Executive Director		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff did not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA Flores met with Elizabeth Martinez - Assistant Executive Director and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested copies of staff and resident roster. LPA conducted interviews with resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5), reviewed file for resident #7(R7) and requested copies of admission agreement, physician's report, face sheet, authorization agreement for payment, preplacement appraisal information, assisted living waiver form, identification and emergency information, letter of notification of increase, acknowledgement of discharge and payment plan. LPA requested a copy of in-service training on resident rights.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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-20230330100849

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: 04/07/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Facility staff did not treat resident with dignity and respect. It is alleged staff's reply was disrespectful and blatant attitude towards resident. Interviews with residents revealed 6 out of 6 residents interview stated staff treats and speaks to the residents in a respectful and mindful manner. Interviews with staff revealed 5 out of 5 staff stated staff use respectful language and communication when speaking to the residents. Documents reviewed revealed R7 signed and initialed admission agreement on 8/22/22, a preplacement assessment was signed on 8/22/22, physician's report dated 8/19/22 notes R7 is ambulatory and can manage finances, acknowledgement of discharge was signed on 3/30/23 and R7 moved out of the facility on 3/30/23. Per executive director, R7 did not disclosed the reason to move out. Facility provided an in-service training to all staff on Resident Rights on 1/19/23.

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 was conducted with Chanel Sanchez Executive Director and Elizabeth Martinez Assistant Executive Director and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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