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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 07/02/2024
Date Signed: 07/02/2024 02:47:51 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
06/27/2024 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240627170558
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: 73DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator Rachelle Reyes TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unnannounced complaint investigation visit for the allegation listed above. LPA met with Administrator Rachelle Reyes and the purpose of the visit was discussed.

LPA conducted the following on todays visit: LPA interviewed Residents #1-#7 (R1-R7), Interviewed Staff #1-#5 (S1-S5), LPA toured the physical plant which included the common rooms and resident room #s 8, 13,16,18, and 25. LPA also reviewed and collected a copy of the staff and resident roster. LPA reviewed and collected documents from R1's file such as: the Facesheet, Physicians Report, Needs and Services Plan, Admissions Agreement, and List of Valuables documentation.

The investigation revealed the following:

Continued on LIC 9099-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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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-20240627170558
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: 07/02/2024
NARRATIVE
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In regards to the allegation "Staff did not safeguard resident's personal items" it is alleged that staff and residents of the facility are stealing information and documents from R1's drawers. (5) of (5) Staff interviewed denied the allegation. (6) of (7) Residents interviewed could not corroborate the allegation. R1 stated to believe that someone in the building was stealing documents from their locked drawer. R1 was unable to detail what and when the specific documents and information was being taken. R1 was not sure if anyone else had a key to their locked drawer. Staff interviewed denied taking any documents or information from R1. Staff also stated that they do not have access to any locked cabinets in residents rooms and only the residents whom the drawer belongs to will have a key. LPA observed R1 to have the key to their locked drawer on their person. File review does not show that there are any incident reports involving R1 having personal items missing. File review does not show that there are items belonging to R1 that R1 signed off on the facility being responsible for. Based on the interviews conducted, files reviewed, and observations conducted 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.

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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2