374604351-10-12-2020-08-AS-DCOA-BUBRK3-20201012130453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604351
Report Date: 10/09/2020
Date Signed: 10/12/2020 01:06:05 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 1		FACILITY NUMBER:	374604351
ADMINISTRATOR:	PETROSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	4149 ROLANDO AVE		TELEPHONE:	(818) 284-2502
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	6	CENSUS: 0	DATE:	10/09/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensee, Linette Manasyan		TIME COMPLETED:	11:45 AM

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	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 Licensee, Linette Manasyan, 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 who may be bedridden. The San Diego Fire Department granted Fire Clearance on August 12, 2020. During today's visit, LPA Correia, accompanied by Licensee Manasyan conducted a virtual tour of the facility. According to Licensee Manasyan there will be no firearms or ammunition stored on site. No pools or bodies of water were observed. Indoor and outdoor passageways are free from obstructions. All window screens are clean and in good repair. Hallways are well-lit. Fire, smoke alarms, and carbon monoxide detectors were all observed and operational. There is a bed for each resident's bedroom with a mattress, mattress pad, bedsprings, and pillows, which are clean and in good repair. There is sufficient closet and drawer space. Each resident bedroom is furnished with a chair, lamp, and a night stand. Resident bathrooms are also in good repair, equipped with handrails, non-skid shower mats, and have sufficient hygiene products for personal use. The facility maintains a sufficient supply of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, hand towels, and washcloths. Facility kitchen maintains a sufficient supply of clean utensils and equipment for proper storage of food items. There is confidential storage area for personnel and resident records. There is a locked storage cabinet for residents' medications and a locked storage area for toxic chemicals. Emergency exit plans, facility policy, residents' personal rights, and COVID-19 precautionary procedures are posted in prominent areas. There is a shaded outdoor activity space, a common room available for visitors, and appropriate activity supplies.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 1	FACILITY NUMBER: 374604351
	VISIT DATE: 10/09/2020

NARRATIVE

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LPA observed a first aid kit and manual maintained at the facility. Facility has a locked laundry area with sufficient space and cleaning supplies available for laundry. There is an operating telephone line. There is emergency lighting and supplies readily available for safety measures. Hot water temperature measured at 115.8 and the facility temperature was set at 77 degrees F.

Component III was completed with the facility representative via FaceTime. Based on today's evaluation, the facility is in compliance with CCR, T22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing is complete and the facility has no deficiencies.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Licensee Manasyan e-mail address. An electronic mail read receipt confirms delivery of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020

LIC809 (FAS) - (06/04)

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