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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604351
Report Date: 10/05/2020
Date Signed: 10/12/2020 12:47:36 PM

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:SENIOR LIVING NORWOODS HACIENDA 1FACILITY NUMBER:
374604351
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:4149 ROLANDO AVETELEPHONE:
(818) 284-2502
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:6CENSUS: 0DATE:
10/05/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant, Anna PetrosyanTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Debbie Correia, conducted an announced Pre-licensing and Component III virtual visit to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. The visit was conducted via FaceTime due to COVID-19. LPA Correia identified herself to Ms. Anna Petrosyan, and explained the purpose of the virtual visit. Licensee's application is to serve six (6) elderly residents, ages 60 and above, five (5) of whom may be non-ambulatory and one(1) of whom may be bedridden. The San Diego Fire Department granted Fire Clearance on August 12, 2020.

LPA Correia and Applicant Petrosyan toured the physical plant, reviewed the facility operation plans to determine the readiness for licensing. LPA Correia also conducted the Component III training with Ms. Anna Petrosyan.

At this point the facility requires further maintenance and installation of necessary furnishings, prior to licensing and an additional visit will be required.

An exit interview was conducted with Ms. Anna Petrosyan and a copy of this report was provided for facility records.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020
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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