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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 05/03/2024
Date Signed: 10/31/2024 09:07:41 AM

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
02/13/2024 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240213092437
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: 75DATE:
05/03/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rachelle RevesTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff mismanaged residents' medication.
Staff did not provide a safe and comfortable environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced subsequent visit at the facility and met with Administrator Rachelle Reves to discuss the purpose for todays visit.

Investigation consisted of: LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, reviewed the medication, did not see any medication laying around.

The investigation revealed: Regarding allegations: Staff mismanaged residents' medication, and
Staff did not provide a safe and comfortable environment for residents. LPA Wesley conducted interviews with 8 of the 11 residents, and they all said that they received their medication from Staff #1 and all the Med Techs who issues medication. LPA Wesley interviewed the maintenance director, wellness coordinator, and the wellness coordinator. The maintenace director found pills on the floor but he said they appear to have continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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 2
Control Number 28-AS-20240213092437
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: 05/03/2024
NARRATIVE
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been in the residents mouth(it has been spit out), all the other staff said its not just 1 person to blame, because the medication is found at random times and is not due to Staff not issuing them. Resident #1 was not admitted to the hospital due to lack of medication, he had health concerns, and the doctor did not put on his discharge papers that he was hospitalized due to missed medication. LPA Wesley also check the training for the Medical Technicians and they were up to date.

Based on the interviews conducted with staff, clients, review of client files and facility records, there was not enough supportive evidence to concur with the reported allegation. 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: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
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