<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604317
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:38:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2023 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20230501131125
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: 6DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Ayad George.TIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client was overmedicated by staff
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA identified herself and discussed the allegation mentioned above with Licensee, Ayad George.

During the investigation, the facility was briefly toured, records requested, and interviews conducted with staff, and outside sources. It was alleged Client #1 (C1) was overmedicated by Staff # 1 (S1). On 04/28/23, S1 was covering another staff’s morning shift and assumed they needed to dispense C1’s medications. S1’s interview confirmed dispensing morning medications to C1. S1 reported they dispensed date 04/29/23 due to 04/28/23 already being punched out from the medication bubble pack. S1 also verified another staff’s initial’s were documented on the Medication Administration Record (MAR) for 04/28/23, as dispensed. Staff interviews revealed being contacted by S1 wanting to know where to sign the MAR since it was already signed by another staff for 04/28/23. It was then discovered C1 was given their morning medications twice, once by the assigned morning staff who left early, then again by the covering staff. C1 was taken to the hospital by S1 for observation for being overmedicated. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20230501131125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 374604317
VISIT DATE: 05/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The hospital records reflected an unintentional medication overdose, first dose was given at 6:30am and the second dose was at 7:30am. The hospital report also indicated a consult with poison control reflected they did not feel that any period of observation was necessary in the emergency room. C1 was discharged back to the facility. S1 was terminated on 04/28/23 for overmedicating C1.

Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 1 is being cited on the attached LIC 9099D. 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230501131125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 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
80075(b)
1
2
3
4
5
6
7
Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated S1 was terminated on 04/28/23. All other staff have medication training on file. Licensee completed and submitted an LIC 9098 Proof of Corrections. POC corrected.
8
9
10
11
12
13
14
Based on interviews and record review the licensee did not ensure medication were given as prescribed for 1 out of 6 clients in care [C1} which posed a potential health and safety risk.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2023 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20230501131125

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: 6DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Ayad GeorgeTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA identified herself and discussed the allegation mentioned above with Licensee, Ayad George.

During the investigation, the facility was briefly toured, records requested, and interviews conducted with staff, and outside sources. It was alleged facility staff are not trained. It was reported staff was not trained in medications but was dispensing medications to clients. S1’s interview revealed accidentally dispensing Client #1’s (C1) morning medications after it was already dispensed for 04/28/23. C1 was given their morning medications by the NOC shift at approximately 6:30am. The staff member from the NOC shift had to leave early. Therefore, S1 came in to cover their shift. S1’s interview confirmed dispensing C1’s medications dated 04/29/23, on 04/28/23 due to date 04/28/23 already being punched out of the bubble pack. S1’s interview further revealed they did not receive medication training from the facility or an outside pharmacy. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230501131125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 374604317
VISIT DATE: 05/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A review of S1’s file confirmed S1 did not have any medication training on file. The house manager’s interview revealed they provided medication training to S1 but forgot to document the training. S1 denied receiving medication training from the house manager. Licensee’s interview revealed the house manager stated the medication training was provided to S1. Therefore, the licensee assumed everything was in order with S1’s training. Licensee explained staff are trained in medications twice a year. S1 was terminated on 04/28/23 for the medication error.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation is deemed unsubstantiated. 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5