374604170-9-8-2023-08-AS-RGAZ-CVGPPQ-20230908112955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604170
Report Date: 09/08/2023
Date Signed: 09/08/2023 11:30:00 AM

Document Has Been Signed on 09/08/2023 11:30 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	NOR LIVING LLC		FACILITY NUMBER:	374604170
ADMINISTRATOR:	RZOK, NAJAH J		FACILITY TYPE:	735
ADDRESS:	9027 AKARD STREET		TELEPHONE:	(619) 335-0566
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY: 6		CENSUS: 5	DATE:	09/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Martha Collins		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by House Manager Martha Collins, to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) ambulatory clients. During today’s inspection, all five (5) clients were at day programs.

LPA, accompanied by M. Collins, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant at 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 109.5 F, bathroom #1 sink was 108.8 F and bathroom #2 sink was 108 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NOR LIVING LLC	FACILITY NUMBER: 374604170
	VISIT DATE: 09/08/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per the House Manager, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers (3) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed House Manager Collins. Interview did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Client files contained required documents. Confidential records were stored in locked areas. House Manager presented proof of current/active business liability insurance and surety bond.

Two (2) out of six (6) staff did not have current 1st aid training. Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with House Manager Collins.

An exit interview was conducted with House Manager Collins, to whom copies of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2023 11:30 AM - It Cannot Be Edited

Created By: Riza Gloria Alvarez On 09/08/2023 at 11:20 AM

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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NOR LIVING LLC	FACILITY NUMBER: 374604170
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two (2) out of six (6) staff which poses a potential healthrisk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit to CCLD proof of completion of First Aid training of two (2) out of (6) staff.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Denise Powell

LICENSING EVALUATOR NAME:

Riza Gloria Alvarez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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