198603172-11-2-2023-28-AS-RORN-CXMVC7-20231116151841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:39:54 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
04/07/2023 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230407114427

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: 67	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Chanel Sanchez		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained an unexplained fracture while in care of staff
Staff did not transfer resident properly resulting in dropping the resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with Administrator Chanel Sanchez who assisted with today's visit.

Regarding the allegation that : Resident #1 sustained an unexplained fracture while in care of staff. The investigation was conducted by the department, and consisted of interviews with staff, residents, review of resident #1's file and review of medical records. The investigation revealed that resident #1 resided at the facility from 1/30/23 - 3/20/23. On 3/5/23, facility sent resident #1 to emergency room due to complaint of right knee pain. A CT scan was done, and was negative for any acute fracture. Resident #1 also mentioned shoulder pain, and medical records indicate that resident #1 did not have a fractured shoulder. Regarding the allegation that : Staff did not transfer resident properly resulting in dropping the resident. The investigation was conducted by the department, and consisted of interviews with staff, residents, review of resident #1's file and review of medical records.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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-20230407114427

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: 11/02/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff interviewed denied that resident #1 was dropped. Staff stated that while transferring resident into wheelchair, resident #1 became still and was lowered onto the floor. Resident #1 was not consistent in statements made regarding being dropped.

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.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2