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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604351
Report Date: 12/11/2023
Date Signed: 12/11/2023 02:24:49 PM


Document Has Been Signed on 12/11/2023 02:24 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:SENIOR LIVING NORWOODS HACIENDAFACILITY NUMBER:
374604351
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:4149 ROLANDO AVETELEPHONE:
(619) 915-6635
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:6CENSUS: 5DATE:
12/11/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Anna Petrosyan, DesigneeTIME COMPLETED:
01:30 PM
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Assistant Program Administrator (APA) Icela Estrada, Regional Manager Leslie Mendiveles and Licensing Program Managers (LPMs) Denise Powell, Jennifer Lott and Simon Jacob conducted a virtual Office Meeting with the late Licensee's Designee and current facility Administrator, Anna Petrosyan, to discuss the succession plan, Emergency Approval to Operate (EAO) process, and pending application items for three Senior Living Norwoods Hacienda residential care facilities.

During today's meeting, the requirements of the Health and Safety Code 1569.193 and California Code of Regulations, Title 22, Section 87111, Continuation of License Under Emergency Conditions, were discussed. Designee confirmed that on November 27, 2023, she notified the Department of the licensee's death which occurred on November 23, 2023, and expressed her intention to continue to operate the residential care facilities for the elderly (RCFEs).

In accordance with Title 22, Section 87111(c)(4), as the party responsible to continue operations, the Designee will file applications for licensure within 20 calendar days of the licensee’s death, by December 13, 2023. As discussed, Designee will submit via email the LIC 200 forms directly to the San Diego Regional Office along with obituary notice and copies of new lease agreements, by close of business on Wednesday, December 13, 2023.

Once the applications have been filed, Emergency Approval to Operate will be issued to the Designee. The Department will decide within 60 days whether to issue a provisional license. An exit interview was conducted, and a copy of this report was provided via email to Administrator and Designee, Anna Petrosyan whose signature on original report confirms receipt of these documents.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Denise PowellTELEPHONE: 619-301-9770
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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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