198603172-8-18-2023-28-AS-RORN-CV8UKY-20230831153955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 08/18/2023
Date Signed: 08/18/2023 01:01:43 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
04/21/2023 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230421144604

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: 74	DATE:	08/18/2023
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Elizabeth Martinez - Assistant Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff are not showering resident timely
Staff are not getting resident out of bed
Staff are not providing resident with special diet
Staff are not offering food if resident misses meals due to dialysis

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Elizabeth Martinez Assistant Administrator of the facility and explained the reason for the visit. Administrator Chanel Sanchez arrived shortly thereafter.

The investigation revealed the following: during the initial visit conducted on 04/27/2023, LPA Kruz Long conducted a tour of the facility, obtained staff and client files, obtained Resident #1's (R1) Records (Physician Report, FACE Sheet, Admission Record, Resident Assessment Form, Shower Log), and also interviewed R1 and the Administrator. During today's visit, LPA Zaragoza interviewed Residents #2 - 9 (R2, R3, R4, R5, R6, R7, R8, R9) and Staff #1 - 6 (S1, S2, S3, S4, S5, S6) . LPA attempted to interview Resident R1, however R1 moved out of the facility and into a Skilled Nursing Facility on 6/9/2023. LPA also obtained copies of the following documentation for C#1: Most Recent Shower Logs, Shower Schedule, and Admission Agreement along with the current staff and resident rosters.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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-20230421144604

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: 08/18/2023

NARRATIVE

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The investigation revealed the following: in regards to the allegation "Staff are not showering residents timely", it is alleged by R1 that staff was providing R1 a bath once every 2 weeks at most, and that they were not keeping R1 clean. During interviews with the residents, seven (7) out of eight (8) could not corroborate the allegation that staff do not help residents with showering needs in a timely manner. The residents who require assistance with bathing state that there is a schedule to keep track of when their shower days are, and that staff always make sure to offer them assistance with showering on their designated days. Interviews with the Staff along with Review of R1's admission agreement revealed that residents are scheduled to be showered at least two times per week at a minimum, and that residents can always request another an additional shower if they want by calling the front desk. Staff state however that they do not force residents to shower, and offer them assistance with showering three (3) times before they document in the resident's shower log that they refused to take a shower on their designated shower day.

In regards to the allegation "Staff are not getting resident out of bed ", R1 alleged that staff were not repositioning or offering to take R1 out of bed often, and that when using the Call Light to notify staff that R1 wanted to get out of bed, R1's calls went willingly ignored. During interviews with the residents, none of them could corroborate the allegation that staff were not getting residents out of bed often or ignoring their needs to get out of bed. R2 explained that staff are very responsive to any request that residents make for assistance and that they are always very helpful, and R6, R7, R8, and R9 explained that while they do not require assistance getting out of bed themselves, they often see staff offering assistance in getting out of bed to their roommates and other residents. Interviews with staff revealed that for bedridden residents they make sure to reposition them once every two (2) hours in order to prevent bed sores from developing. Additionally Staff explained that they always offer assist bedridden residents out of bed for all meal times and for planned activities as well, but will not remove them from bed forcibly if they do not wish to get out of bed.

In regards to the allegation "Staff are not providing resident with special diet", it was alleged by R1 that staff were not meeting R1's specialized renal diet, and continued to feed R1 bacon and hash browns for breakfast even though they were not supposed to be eating it according to their physician. In interviews with the residents, none of them could corroborate the allegation that staff do not met the dietary needs of residents who have specialized diets. According to R4 who is also on a Renal Diet and also goes to dialysis, the facility staff are made aware of their dietary requirements and that they do not eat meat, and the kitchen staff always make sure to provide alternatives for R4. All other residents similarly expressed that residents who have specialized diets are accommodated when they inform the kitchen staff of their needs. In an interview with S6 the Dietary Cook for the facility, S6 explained either staff or the resident themselves inform him of their specialized diets if they have any and he makes sure to provide them food alternatives if necessary.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230421144604

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: 08/18/2023

NARRATIVE

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Other staff members explained that they are informed of specialized diet through the resident's physician's report, which they then provide the kitchen staff so they are aware of any foods the residents of the facility need to avoid.

In regards to the allegation "Staff are not offering food if resident misses meals due to dialysis", it was alleged by R1 that staff were not offering R1 breakfast before they went to dialysis at 9 AM nor lunch after they returned around 3 PM because the kitchen was closed. R1 explained that they only had one meal per day while staying at the facility and that was dinner. During interviews with the residents, none of them could corroborate the allegation that staff do not provide breakfast or lunch to residents who go to dialysis in the morning. In an interview with R4 who was the only resident available who currently goes to dialysis, R4 explained that the staff do offer R4 breakfast before they go to dialysis, and that the staff always make sure to provide R4 food to take with them to the dialysis center. In interviews with the facility staff, they explained that they always offer breakfast to residents before they go to dialysis, and residents have the option to take something with them to-go from the kitchen before they leave for dialysis. Additionally S3 and S6 stated that there is always plenty of food leftover from lunch so residents can also get lunch when they return as well.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

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