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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:54:31 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
05/11/2022 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220511142439
FACILITY NAME:NORWALK RETIREMENT VILLAFACILITY NUMBER:
198603172
ADMINISTRATOR:PHAM, LISAFACILITY TYPE:
740
ADDRESS:11515 FIRESTONE BLVDTELEPHONE:
(310) 857-8218
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:80CENSUS: 75DATE:
05/03/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rachelle RevesTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Questionable death
Resident fell while in care
Staff are mismanaging resident medication
Staff did not seek medical treatment in a timely manner
Staff are not responding to residents calls
Staff left resident's in soiled diapers for extended period of time
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: copy of resident and staff roster, interviews with clients, staff, and obainted copies of specific documents.

Regarding allegation: Questionable death It appears that the resident was outside smoking and they asked him to come for lunch, 20 minutes passed and he appeared to be in the sleeping in the chair. Staff tried to wake him and he was not responding, there was no pulse and 911 was called. DNR was noted in the residents file.
Regarding allegation: Resident fell while in care. it appears that resident #2 had an unwitnessed fall

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-20220511142439
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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in care. it appears that resident #2 was in bed and said his legs got very weak. Staff #2 noticed he was speaking differently, his speech was blurred. She tried to assist him but he was not able to bear weight on his legs, so she called 911 for a possible stroke.

Regarding allegation: Staff are mismanaging resident medication LPA interviewed residents and there is no indication that staff are mismanaging the residents medications. Resident #3 left the facility and did not inform staff he was leaving for the weekend. When he came back on the following Monday, they gave him his medication. There is no way they are supposed to give him the missed medication for 2 days unless the doctor said it was okay to do so, and according to the complainant the resident takes 4 sets of medication in 1 day.

Regarding allegation: Staff did not seek medical treatment in a timely manner. In regards to Resident #1,and #2 the facility sought medical treatment in a timely manner. Resident #1 had information in his file, and Resident #2 was under Hospice care.

Regarding allegation: Staff are not responding to residents calls. LPA Wesley interviewed staff #1 and she indicated that the staff are responding to residents calls because she answers them. LPA interviewed resident #5 and she couldn't recall stating that the staff#1 didn't answer her calls and hangs up. She did say that they answer the phones now. LPA asked Resident #3, #5, and resident #9 and they all indicated that they calls are answered.

Regarding allegation: Staff left resident's in soiled diapers for extended period of time. LPA Wesley interviewed resident #3, #4, and #5. Resident #3 and #5 informed the LPA that they couldn't remember. LPA interviewed resident #4 she said she doesn't even remember wearing diapers in 2022.

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)
Page: 2 of 2