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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604317
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:40:00 PM

Document Has Been Signed on 05/16/2023 03:40 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:NOR LIVING 2 LLCFACILITY NUMBER:
374604317
ADMINISTRATOR:GEORGE, AYADFACILITY TYPE:
735
ADDRESS:1950 AVON LANETELEPHONE:
(619) 335-0566
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: DATE:
05/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Licensee, Ayad George.TIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management- Deficiencies visit. LPA identified herself and discussed the purpose of the visit with Licensee, Ayad George.

The reason for the visit was to issue a deficiency that was identified during a complaint investigation. It was reported Staff # 1 (S1) did not have medication training on file and was dispensing medications to clients. There was an unintentional medication overdose error made by S1 on 04/28/23. A review of facility records indicated S1 did not have any medication training on file. S1 confirmed not receiving any medication training from the facility. However, the house manager stated she provided medication training to S1 but forgot to document it. The house manger stated the medication training also included one week of shadowing. Title 22 Regulations requires documentation of training.

Based on interviews and record review, a deficiency is being cited on the attached 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Licensee, Ayad George whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/16/2023 03:40 PM - It Cannot Be Edited


Created By: Natasha Persaud On 05/16/2023 at 08:58 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 2 LLC
FACILITY NUMBER: 374604317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2023
Section Cited
CCR
80066(a)(6)

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Personnel Records. The licensee shall ensure that personnel records are maintained on...each employee. Each personnel record shall contain the following information: Documentation of...training and/or experience specified in licensing regulations for the type of facility in which the employee works.
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Licensee agreed to ensure all staff receive completed medication training prior to dispensing medications and document all medication training. Licensee stated S1 was terminated on 04/28/23. Licensee agreed to attend Personnel Records training along with staff that document training and provide proof of training by POC due date.
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This requirement is not met as evidenced by: Based on interviews and record review the licensee did not document medication training for 1 out of 5 staff [S] which posed a potential health and safety risk to clients in care.
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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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


LIC809 (FAS) - (06/04)
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