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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:34:10 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
04/18/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230418144527
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: 76DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Rachelle ReyesTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not prevent resident from using illegal narcotics in the facility.
Staff do not ensure medication is dispensed in a timely manner.
Staff dispensed medications incorrectly.
Staff do not ensure residents medications are replenished timely.
Residents left in soiled clothing for extended period of time.
Facility did not maintain residents account ledgers.
Staff do not address safety measures to prevent residents wandering away.
Staff did not prevent unauthorized persons from sleeping in the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Jose Villalobos and Tyler Reyes conducted a subsequent visit for the allegations above. LPA's met with Executive Director Rachelle Reyes and the purpose of the visit was discussed.

Previous visits conducted by LPA Villalobos and Kruz Long between 4/19/23 and 8/25/23 consisted of the following: Tours of the physical plant. Observations of the facilities food supply.Copies of the staff and resident rosters were obtained. Documents from residents #1-#4 (R1-R4) files were collected. Copies of the food menu, emergency evacuation plan, fire drill log, and activity calendar were reviewed and collected. Staff #1 (S1) was interviewed, and residents #3-#9 (R3-R9) were interviewed. On todays visit LPA's interviewed Staff #2-#5 (S2-S5), R2 and Residents #10-12 (R10-R12). LPA reinterviewed R4, R8-R9. R1 and R13 are no longer in the facility and were unavailable for interview. LPA collected financial ledger for R4 between February2023-April 2023. LPA also collected physicians reports, medication records and any incident reports for R7 and R10-R11. The investigation revealed the following:
CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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 4
Control Number 28-AS-20230418144527
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: 02/29/2024
NARRATIVE
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In regards to the allegation "Staff did not prevent resident from using illegal narcotics in the facility" it was alleged that staff did not prevent R13 from using illegal drugs in the facility. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. No staff or residents interviewed were able to say they observed R13 to be using illegal narcotics in the facility. Interviews state that R13 had a history of alcohol abuse and smoking in his room. Interviews state that staff addressed the issues with the resident multiple times. File review shows that R13 received warning notices for smoking cigarettes in the facility as well as for their behavior towards others between the months of October-December 2023. File review and interviews do not show that R13 was using illegal narcotics in the facility. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

In regards to the allegation "Staff do not ensure medication is dispensed in a timely manner." it was alleged that medications were being provided to residents up to 2 hours late. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Interviews with staff stated that it is medications management protocol to have a 2 hour window for each medication, meaning if a medication is prescribed to be taken at 8am, it can be provided between 7am-9am. No residents interviewed had issues with the timely manner that they received their medications. LPA did not observe medication errors from staff for files reviewed. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

In regards to the allegation "Staff dispensed medications incorrectly" it was alleged that staff provided residents the incorrect medications. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. LPA did not observe medication errors from staff for files reviewed. Interviews with residents did not state staff have provided any residents the wrong medications. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Continued on LIC 9099-C
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230418144527
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: 02/29/2024
NARRATIVE
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In regards to the allegation "Staff do not ensure residents medications are replenished timely" it is alleged residents will be out of specific medications for a few days before their prescription refills are received. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Interviews did not state that has happened to residents in the facility. Residents interviews did not have that experience. LPA was not provided with information as to which residents were left without medications. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

In regards to the allegation "Residents left in soiled clothing for extended period of time" it was alleged that staff were not changing resident diapers in a timely manner. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Staff interviews state that it is part of the caregivers duty to conduct check on all residents who need diaper changes every 2 hours. Residents are also able to communicate with staff and staff will assist residents with diaper changes. Interviews with residents confirmed the information. LPA was not informed of which residents were not being changed by staff as needed. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

In regards to the allegation "Facility did not maintain residents account ledgers" it was alleged that the facility was not accurately handling resident finances. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Details provided state that R4 was not provided their monthly P&I funds in early 2023. Interviews with staff state that R4 had an overdue month of owed rent because they failed to pay for the month of January in 2023 and so R4 made an agreement with the facility to pay off the owed balance by paying $100 of their funds monthly until it was paid off. R4 confirmed the information. As of today, overdue bills has been paid and LPA observed R4's account ledger to reflect an accurate balance along with an accurate P&I provided to R4 monthly. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Continued on LIC 9099-C
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230418144527
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: 02/29/2024
NARRATIVE
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In regards to the allegation "Staff do not address safety measures to prevent residents wandering away" it was alleged that Staff fail to prevent R7,R10-R11 from wandering out of the facility. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Interviews state that the residents do not wander out of the facility and such incidents have not occurred. Review of the physicians report for R7 and R10-R11 show that the residents cannot leave the facility unassisted. There are no incident reports on file showing the residents have left the facility unassisted. Interviews with the residents conducted do not state they leave the facility unassisted. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

In regards to the allegation "Staff did not prevent unauthorized persons from sleeping in the facility" it was alleged that homeless people have entered the facility and slept in the common room. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Staff and residents interviewed stated to not have any knowledge of such an incident occurring. File review did not show any reports involving a homeless person sleeping inside the facility. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Exit Interview conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4