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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603172
Report Date: 11/21/2023
Date Signed: 11/21/2023 04:14:49 PM

Document Has Been Signed on 11/21/2023 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 VILLAFACILITY NUMBER:
198603172
ADMINISTRATOR:CHANEL A. SANCHEZFACILITY TYPE:
740
ADDRESS:11515 FIRESTONE BLVDTELEPHONE:
(562) 379-9200
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 80CENSUS: 66DATE:
11/21/2023
TYPE OF VISIT:Case Management - Annual ContinuationANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chanel SanchezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted a required 1 year (annual continuation) visit. LPA met with Administrator Chanel Sanchez and Assistant Administrator Elizabeth Martinez to discussed the purpose of today’s visit.

The facility property is a two story commercial building, licensed to serve 80 non-ambulatory residents ages 60 and above, of which 10 can be bedridden. The designated rooms for bedridden residents are rooms 1, 3, 5, 7, and 9, The facility has an approved hospice waiver for 30 residents. There are a total of 40 resident rooms. LPA Wesley used the care tools to conduct the visit, and interview staff and residents.

LPA toured the facility and visited medication room (health services office), hot water was tested measuring 112.4-113.3 degrees F.

The Last fire drill was conducted on 10/19/23. LPA Wesley interviewed 9 residents and 5 staff. LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed 7 total fire extinguishers, 1 in the kitchen, 2 floor one(hallways), 2 floor two(hallways), 1 in the administrators office, and 1 underneath the front desk.

There are no deficiencies according to the California Code of Regulations, Title 22.

Exit interview conducted.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2002
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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