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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603728
Report Date: 08/21/2025
Date Signed: 08/21/2025 04:20:26 PM

Document Has Been Signed on 08/21/2025 04:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAS IIFACILITY NUMBER:
198603728
ADMINISTRATOR/
DIRECTOR:		WOOD, CHERIEFACILITY TYPE:
740
ADDRESS:15218 WILDER AVENUETELEPHONE:
(562) 219-7402
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 6DATE:
08/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Richel Feria, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA was met by Richel Feria, the Caregiver and explained the purpose of the visit. The Administrator, Cherie Wood arrived shortly after and the LPA explained the purpose of the visit. Facility is licensed for residents the age range of 60 and over. Six (6) non-ambulatory of which one (1) may be bedridden in room #5. Hospice waiver for four (4) residents. There are (1) bedridden and (1) hospice residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an updated infection control plan dated 11/01/2024 in place. The facility staff and residents continue to practice hand washing and disinfecting the facility each shift. The facility has sufficient PPE supplies.

Operational Requirements: Facility is licensed for residents the age range of 60 and over. Six (6) non-ambulatory of which one (1) may be bedridden in room #5. Hospice waiver for four (4) residents which is within the fire clearance requirement. LPA observed current Liability insurance in place. The facility has a dementia care plan to accept or retain residents with dementia. The fire drill was last conducted on 06/17/2025.

Physical Plant/Environment Safety: A tour of the single-story facility included: four (4) resident bedrooms, one (1) staff bedroom, one (1) resident bathroom, living room, kitchen, laundry room, front yard, backyard, and attached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The front and backyard are well maintained.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 VILLAS II
FACILITY NUMBER: 198603728
VISIT DATE: 08/21/2025
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Physical Plant/Environment Safety: There is a shaded seating area for the residents located in the backyard. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested and measured at 119.1 degrees F, which is within the required 105 - 120 degrees F. Sharps are kept locked in a kitchen cabinet. Chemicals and cleaning supplies are kept locked under the kitchen sink. The bathroom was clean and had the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid material. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in the hallway. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide detector was tested and properly operating. A fire extinguisher was observed at the kitchen and is fully charged.

Staffing: The facility has sufficient staff to provide care and supervision to the residents. The staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records-Training: LPA reviewed five (5) staff files that include: Personnel Record, Health clearance, TB Result, Criminal Background Clearance, Employee Rights, 1st Aid/CPR training, Medication Management and Staff Training. The RCFE administrator certificate expired on 08/19/2027.

Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program.

Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Sufficient food supply is stored in the kitchen consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Pesticides and cleaning supplies are kept away from the food preparation areas. Per administrator, there are no residents that have a modified diet.


NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 VILLAS II
FACILITY NUMBER: 198603728
VISIT DATE: 08/21/2025
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Incident Medical and Dental: Medications were reviewed for six (6) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are centrally stored and in their original containers. Medications are administered as prescribed by the Physician. Medications are bubbled packed. LPA reviewed six (6) residents medication files and observed the Centrally Stored Medication Destruction Record in file. The first Aid kit was observed and has all required items.

Resident Records/Incident Reports: LPA reviewed five (5) resident files that include: the Face Sheet, Admission Agreements, Physician's Reports, TB Clearance, Ambulatory Status, Pre-Placement Appraisal, Functional Capability Assessment, Resident Appraisal, Physician’s Orders, Appraisal/Service and Needs Plan, and Personal Rights.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E dated 08/01/2025 is in place with contact numbers and at least 2 relocation sites.

Residents with Special Health Needs: There are no residents receiving home health services and one (1) resident receiving hospice care. The facility has a hospice care plan. There are no residents with prohibited health conditions. Based on record review, LPA observed that Resident #1 (R1’s) file did not have a written Physician’s Order for a half bed rail.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to Cherie Wood, Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2025 04:20 PM - It Cannot Be Edited


Created By: Daniel Konishi On 08/21/2025 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NORWALK VILLAS II
FACILITY NUMBER: 198603728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(3) A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that Resident #1 (R1’s) file did not have a written physician’s order for a bed rail which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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The Administrator will send Resident #1 (R1's) written Physician’s Order for the half bed rail to the LPA by POC due date. Daniel.Konishi@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
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