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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 08:27:35 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
03/18/2022 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220318145550
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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Staff did not prevent strangers from breaking into residents room.
Staff did not notify the police of incident.
Staff did not notify residents authorized representative of incident.
Financial fraud.
Facility phone is in disrepair.
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 03/22/2022. 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-20220318145550
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:

· Staff did not prevent strangers from breaking into residents’ room. It is alleged on or around November or December of 2021, Resident 1(R1) room was broken into and used by strangers to take a shower and use the restroom. Six (6) out of six (6) staff interviewed all deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. Per Staff 1 (S1) the facility has always maintained unarmed patrol. LPA obtained security service agreement dated January 05, 2022, and it states unarmed patrol of three stops per day between 8pm to 8am, 7 days a week. Patrol officer will remove loiters, transients, report graffiti, property damages or hazards observed during patrol. LPA could not locate any SIR on or around November or December of 2021, that indicated this facility had been broken into.

· Staff did not notify the police of incident. It is alleged on or around November or December of 2021, staff did not notify the police of alleged break-in into resident’s room. 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 verified with Norwalk Sheriff’s Department if any calls were placed on or about November or December to report any break-ins into the facility, per Ofr. Montiel, no calls log to that location was made for break-ins.

· Staff did not notify residents authorized representative of incident It is alleged on or around November or December of 2021, family of R1 was not notified of strangers breaking into R1’s room. Six (6) out of six (6) staff interviewed all deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. R1 has since been relocated and LPA was unable to interview. LPA was able to interview Witness 1 (W1). LPA could not find any documentation that an alleged break in occurred in R1’s room on or around November or December of 2021.

· Financial fraud. It is alleged that R1’s money was being sent to an unknown bank account and only contained $1 on R1’s “Direct Express” card. 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 reviewed R1’s file and could not locate anything out of the ordinary. LPA located a signed document from R1 stating R1 collected all his belongings when R1 vacated the facility.

· Facility phone is in disrepair. It is alleged that the facility phone is in disrepair and residents’ families cannot get a hold of staff. 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 dialed facility listed phone number and staff answered with a greeting. LPA also observed resident using the phone to make a call during visit.

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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