198603172-7-31-2023-28-AS-LHIS-CUGN7N-20230807101302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 07/31/2023
Date Signed: 07/31/2023 03:20:09 PM

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
07/27/2023 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230727155003

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:	07/31/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Chanel Sanchez, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not report unusual incidents as required
Staff did not adhere to resident's admission agreement regarding payments
Resident has an exposed pipe in his bedroom

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an initial complaint visit in response to the allegation listed above. LPA met with Administrator, Chanel Sanchez, and Elizabeth Martinez, Business Office Manager.

Regarding the allegation that: Staff did not report unusual incidents as required. The investigation consisted of interviews with Reporting Party, Administrator, and Staff #1 and review of staff roster, and resident roster.
Reporting Party (RP) stated that there was an altercation in October 2022, involving resident #1 and resident #2.The RP also stated that the incident was observed by Staff #2 and Staff #3, and was not reported as required. Resident #1 and Resident #2 are no longer residents of the facility, and were not interviewed. Staff #2 is no longer working at the facility and was not interviewed. Staff #3 was not working at the facility when the alleged incident occured. Staff #3 began working at the facility in February 2023, and therefore was not at the facility on the date of the alleged incident. Administrator and Staff #1 stated that they were not aware of the incident.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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-20230727155003

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: 07/31/2023

NARRATIVE

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Regarding the allegation that: Staff did not adhere to resident #3's admission agreement regarding payments. The investigation consisted of interviews with Administrator, Staff #1, resident #3, and review of resident #3's admission agreement and Payment Plan. Administrator and Staff #1 stated that the facility has developed a payment plan for resident #3, due to the fact that resident #3 has an outstanding balance, and is not current on their rent. Resident #3 did not dispute the admission agreement or payment plan that is in place at the facility.

Regarding the allegation that: Resident #3 has an exposed pipe in their bedroom. The investigation consisted of interviews with Administrator, Staff #1, resident #3, and tour of resident #3's room. Administrator and Staff #1 stated that they were unaware of an exposed pipe in resident #3's room. LPA toured room and did not observe an exposed pipe. LPA asked Resident #3 where the exposed pipe was, and resident #3 went to the room, and lifted a trash can on the floor, to show LPA the pipe. LPA observed on the right hand side of the room, a small area on the floor, next to the wall that has a partially exposed pipe. LPA did not observe that this is a health and safety hazard to resident(s). Administrator and Staff #1 stated that this had not been brought to their attention. They stated that they will move resident #3 to another room, if resident #3 would like to be moved. When asked if resident #3 would like to be moved to another room, he stated "I don't care".

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

Exit interview was conducted with Ms. Sanchez, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC9099 (FAS) - (06/04)

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