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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 04/24/2023
Date Signed: 04/25/2023 08:36:26 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
01/04/2022 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220104123415
FACILITY NAME:NORWALK RETIREMENT VILLAFACILITY NUMBER:
198603172
ADMINISTRATOR:PHAM, LISAFACILITY TYPE:
740
ADDRESS:11515 FIRESTONE BLVDTELEPHONE:
(310) 857-8218
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:80CENSUS: 65DATE:
04/24/2023
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Administrator SanchezTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident with Covid-19 is not getting sufficient care.
Food prepared and served to resident was unsafe.
Facility is dirty.
Untrained staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit on 04/24/23 stemming from initial complaint visit conducted by LPA Wesley on 01/13/2022. LPA was met by Staff(S1) and explained the purpose of the visit. LPA and S1 were later met by Administrator Chanel Sanchez.

LPA conducted a physical tour of facility, requested, and obtained Personnel Report (LIC 500), Resident Roster, copy of Resident 1(R1) Face sheet and other pertinent documents regarding this investigation.

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: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
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-20220104123415
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: 04/24/2023
NARRATIVE
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Allegations:

· Residents with COVID-19 is not getting sufficient care. It is alleged on or around December 28, 2021, Resident 1(R1) was ill with an infectious disease. R1 was not properly checked on in a timely manner and ignored by staff when R1 requested assistance. Six (6) out of six (6) staff interviewed all deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA Ramirez obtained and reviewed Special Incident Report (SIR) dated 12/28/2021. Per facility Mitigation Plan, staff will check on COVID-19 positive residents every 2 hours. LPA observed signage around the facility hallways promoting social distancing and the use of face masks.

· Food prepared and served to resident was unsafe. It is alleged on or around December 28, 2021, R1 was provided food that was not properly heated and contained a wire. Six (6) out of six (6) staff interviewed all deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA toured facility kitchen while staff was finishing serving breakfast. LPA observed staff wearing hair nets and gloves. LPA observed various commercial refrigerators with temperature reading at 36 degrees F. LPA observed raw meats in metal trays wrapped with plastic wrap. Per Staff 6 (S6) meals are prepared fresh on site. Facility groceries are delivered every Wednesday. Per S6, residents with infectious diseased are provided meals in red trays and given disposable plates and utensils. LPA verified three (3) food handler certificates for staff in kitchen during visit.

· Facility is dirty. It is alleged on or around December 28, 2021, R1’s temporary room for isolation was dirty and had feces in the toilet. Six (6) out of six (6) staff interviewed all deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA toured random rooms on second floor. Rooms were observed to clean, and no hazards were seen. Per Administrator Sanchez, housekeeping disinfects and cleans resident rooms on the daily.

· Untrained staff. It is alleged on or around December 28, 2021, staff did not know how to properly assist a resident that may have fallen or dispense medications. LPA verified medications training, and CPR/First Aid training certificates for two (2) of the facility senior staff. LPA verified Administrator’s Certificate for Chanel Sanchez.

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 via email due to printer problem.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
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