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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604092
Report Date: 12/21/2022
Date Signed: 12/21/2022 10:55:41 AM


Document Has Been Signed on 12/21/2022 10:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SENIOR LIVING NORWOODS HACIENDAFACILITY NUMBER:
374604092
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:35 EL RANCHO VISTATELEPHONE:
(818) 284-2502
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: 6DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Caregiver Elena MarrufoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Tammer de los Santos visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Caregiver Elena Marrufo to whom LPA disclosed the purpose of the visit.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; signs in the facility to promote hand hygiene, cough / sneeze etiquette, symptom, and transmission awareness; face coverings worn by staff; hand sanitizer readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products and personal protective equipment.

The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by February 19, 2023.

No deficiencies were cited during today’s visit. An exit interview was conducted with Caregiver Elena Marrufo, and copies of this report and Licensee Rights (LIC 9058) were provided at the conclusion of the visit. Facility representative’s signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Tammer DeLosSantosTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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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