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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603172
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:13:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
07/30/2024 and conducted by Evaluator Sanjay Vaid
COMPLAINT CONTROL NUMBER: 28-AS-20240730121748
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:
08/06/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Francine Reyes-Wellness DirectorTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff do not assist resident with obtaining and distributing medication as prescribed.
Staff do not ensure facility is clean and sanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vaid conducted an initial visit to investigate the above allegations. At 8:50 am, LPA met with Wellness Director Francine Reyes and explained the purpose of the visit. Administrator is on leave.

The investigation consisted of the following: LPA obtained and reviewed staff and client roster, physician report, appraisal needs plan, face sheet, admissions agreement and medication administration records(MARS) for the month of July and August 2024 regarding R1. LPA conducted interviews with staff 1- 6 (S1-S6). LPA interviewed residents 1-5 (R1 -R5). LPA Vaid conducted tour of the physical plant and did not observe any deficiencies or health and safety concerns.

Allegation: Staff do not assist resident with obtaining and administering medication. It is alleged that staff are not assisting residents with obtaining and administering their medications. Five (5) out of (5) staff interviewed deny the allegation. CONTINUED on 9099 C.....


Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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 3
Control Number 28-AS-20240730121748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172
VISIT DATE: 08/06/2024
NARRATIVE
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Seven (7) out of (7) residents interviewed, denied that the staff does not assist with obtaining and administering their medications. All residents interviewed state that the staff is proactive in ordering and obtaining the prescribed medications from the physician and pharmacy. By R1’s accounts medication has been given to them daily as prescribed. The facility contacted the pharmacy on 06/18/2024 to order refills for the following medications.

1. Lisinopril ½ tablet, once daily
2. Folic acid 1mg tablet once per day.

The facility contacted the pharmacy on 06/21/24 and 06/25/24 for follow-up on the medications. The prescription 1 was filled and sent to facility on 06/28/24. The second prescription was not filled due to Insurance billing delays. LPA reviewed medication orders for R1, all medications have been prescribed as physicians orders as indicated in the Medication Administration Records (MARS) in the entire month of July 2024 and six (6) days in August 2024. Reviewed four (4) residents MARS, all medications have been administered as prescribed. Based on interview, resident #1's prescription medication were not refilled in a timely manner due to insurance billing delays causing resident #1's prescription medications not being administered from July 1, 2024, to July 6, 2024. The medication delay was acknowledged by the pharmacy who then contacted the physician on June 25,2024 to reinstate medication for R1 by 06/27/24. Based on LPA's interviews and record review, 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 allegations are unsubstantiated.

Allegation: Staff do not ensure facility is clean and sanitary. It is alleged that staff did not ensure that the resident was provided with housekeeping services and the facility is not kept in sanitary conditions. Five (5) out of (5) staff denies this allegation. Seven (7) out of (7) residents deny this allegation. Interviews with staff members revealed that housekeeping is done daily, and room checks (taking out trash, replacing paper products) are completed daily with the deep cleaning done once a week, bedsheets are changed twice per week. Walls and furniture are dusted twice per week. The bathroom sink and floors are cleaned daily. Housekeeping is performed daily. Staff members have not heard any residents complaining about this issue recently. Interviews with staff indicated that housekeeping staff provide housekeeping services like, cleaning and room checks daily.
CONTINUED on 9099C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240730121748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NORWALK RETIREMENT VILLA
FACILITY NUMBER: 198603172
VISIT DATE: 08/06/2024
NARRATIVE
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LPA reviewed the facility's housekeeping/maintenance schedule as well as housekeeping deep clean schedules and duties for July 2024. The documents revealed that they have staff assigned to clean the residents’ rooms daily and deep clean on a weekly basis. According to R1 recollection housekeeping comes every day to clean and tidy the room. Based on LPA's interviews and record review, 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 allegations are unsubstantiated.

Exit interview held, and a copy of this report was provided to Francine Reyes.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3