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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:15:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/28/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240528123331
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:
05/31/2024
UNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Janice Anguiano – Business Office Manager TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not preventing resident from harrassing other resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced visit at the facility to investigate the above allegation. LPA met with Janice Anguiano – Business Office Manager and explained the purpose for todays visit.

Investigation consisted of the following:
LPA obtained staff and resident rosters, copies of documents within R1's file, interviews with 3 staff and 7 residents.

(continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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-20240528123331
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172
VISIT DATE: 05/31/2024
NARRATIVE
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The investigation revealed the following:
Allegation: Staff are not preventing resident from harassing other resident while in care.
It is alleged that roommates R1 and R2 are having verbal altercations, R1 is being harassed by their roommate R2 and staff have done nothing to diffuse the situation. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation and stated they have not been told about altercations between R1 and R1 prior to todays visit. Interview with S3 revealed that R1 was experiencing aggressive behaviors over incidents that are outside of the reported allegation, R1 is not in the facility as they have been sent for a psychiatric evaluation. LAP interviewed R2 and they denied the above allegation and stated they have never had any altercations with anyone at facility. LPA reviewed incident reports and there was nothing noted about R2 having aggressive behaviors or altercations with residents. LPA interviewed a total of 7 residents and 7 out of 7 residents denied the above allegation, stating that when there are verbal altercations staff will mediate the situation, try to solve the problem and separate those involved in the altercation.

Based on statements and interviews conducted with staff and residents and review of resident files, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Janice Anguiano.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
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