198603172-9-21-2023-28-AS-TVAO-CWJMPZ-20231012094755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:24:37 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
09/13/2023 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230913084158

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: 72	DATE:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Elizabeth Martinez and Chanel Sanchez		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff left resident in soiled incontinence briefs.
Unlawful eviction.
Staff did not update SSI on residents living situation for payment(s).
Facility providing confidential information to unauthorized party.
Facility not assisting resident with medication orders.
Facility not assisting resident with wound care orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial complaint visit to investigate the above allegations. LPA met with Elizabeth Martinez (Business Office Manager/Assistant Administrator) and Chanel Sanchez (Executive Director/Administrator) and discussed the purpose of today’s visit.

During this visit, LPA obtained a copy of the resident and staff rosters and reviewed Resident #1’s (R-1) file and obtain relevant documentation. LPA also interviewed Staff #1 (S-1) through Staff #5 (S-5) and Resident #2 (R-2) through Resident #4 (R-4). Resident #1 (R-1) refused to be interviewed.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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-20230913084158

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: 09/21/2023

NARRATIVE

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Allegation: Staff left resident in soiled incontinence briefs. Staff interviews and documentation reviewed revealed that R-1 refuses to allow staff to change R-1’s soiled incontinence briefs. Per staff interviews, R-1 also refuses to allow staff to clean R-1’s room (in general and anything involving incontinence). Per staff interviews, staff ensure that R-1 has plenty of incontinence supplies such as adult incontinence briefs, wipes, ect. (beside R-1’s bed) as R-1 is independent in incontinence care. Resident interviews revealed that R-1 refuses to allow staff to clean R-1’s room and is often yelling and/or cursing at staff and hitting the walls. Per resident interviews, staff clean resident rooms daily. Interviews and documentation review does not corroborate this allegation.

Allegation: Unlawful eviction. Staff interviews and file review for R-1 revealed that an eviction notice was issued to R-1 on 08/31/23 due to repeatedly violating house rules. Staff interviews and documentation review does not corroborate this allegation.

Allegation: Staff did not update SSI on residents living situation for payment(s). Staff interviews and file review for R-1 revealed that on 02/08/23 this facility notified the Social Security Administration office of R-1’s admission to this facility and requested the board and care rate to be implemented. Per staff interviews, the board and care rate was implemented effective 06/01/23 (as R-1 had an overpayment from the previous placement/facility). Staff interviews and documentation review does not corroborate this allegation.

Allegation: Facility providing confidential information to unauthorized party. Staff interviews and file review for R-1 revealed that R-1’s family member is noted as R-1’s “primary” contact. Per staff interviews, the listed family member for R-1 (noted on R-1’s face sheet) is the only person that is contacted. Staff interviews and documentation review does not corroborate this allegation.

Allegation: Facility not assisting resident with medication orders. Staff interview revealed that R-1 went to a medical appointment with R-1’s primary physician on 09/05/23 (on R-1’s own) and allegedly received orders for new medication. Per staff interview, this was discovered during a meeting that was held with R-1 on 09/15/23. Per staff interview, R-1 did not provide staff with any new medication orders. Staff have reached out to R-1’s primary physician to obtain clarification and have been unsuccessful in reaching R-1’s primary physician. Staff interview and documentation review does not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230913084158

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: 09/21/2023

NARRATIVE

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Allegation: Facility not assisting resident with wound care orders. Staff interview revealed that R-1 went to a medical appointment with R-1’s primary physician on 09/05/23 (on R-1’s own). Per staff interview, this was discovered during a meeting that was held with R-1 on 09/15/23. Per staff interview, R-1 did not inform staff of any orders for wound care. Staff interview and documentation review does not corroborate this allegation.

Based on record review and interviews conducted the findings indicate, 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.

An exit interview conducted, appeal rights and a copy of this report was provided to Chanel Sanchez

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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