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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604351
Report Date: 03/02/2021
Date Signed: 03/02/2021 05:06:18 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 HACIENDAFACILITY NUMBER:
374604351
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:4149 ROLANDO AVETELEPHONE:
(818) 284-2502
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:6CENSUS: 7DATE:
03/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Anna PetrosyanTIME COMPLETED:
03:30 PM
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Licensing Program Manager (LPM) Rebecca Hedgecock conducted an unannounced case management visit to issue citations in response to unrelated deficiencies observed during a complaint virtual-visit to the facility on February 24, 2021. LPM was greeted by staff Lissette Alcaraz who granted LPM entry into the facility. LPM disclosed the reason for the visit to the staff. LPM toured the facility, observed residents in care and reviewed records. Administrator Anna Petrosyan arrived shortly after LPM's arrival.

During a virtual visit to the facility on February 24, 2021, LPAs Nguyen and Segura observed the following deficiencies:

· It was discovered that on or about the first week of February 2021, Licensee Manasyan accepted a 7th (seventh) resident [See LIC 811 Confidential List of Names]. Facility is licensed for 6 (six) residents. Licensee was over capacity by 1 (one) resident.

· Cabinets that housed residents’ medications were observed with keys inserted and left in the locks resulting in medications being accessible to residents in care. At time of 2/24/21 visit, licensee removed and secured keys.

· Virtual tour of the facility revealed 2 steak knives in the kitchen sink unattended. Licensee immediately washed and secured the knives. It was also observed that the door to laundry/utility room was unlocked and open. Laundry detergents and cleaning chemicals were observed accessible to resident. Virtual tour of the facility further revealed 5 (five) six-gallon containers and 6 (six) one-gallon containers of paint with lids stored on the side patio.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Rebecca HedgecockTELEPHONE: (619) 241-0535
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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 4
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
FACILITY NUMBER: 374604351
VISIT DATE: 03/02/2021
NARRATIVE
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Deficiencies are being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and listed on an LIC 809-D. Immediate civil penalties are also being assessed and listed on the attached LIC 421IM. Administrator will be provided a copy of their rights (LIC9058 01/16), along with a copy of this report along with form LIC 421IM via electronic mail. A read receipt will be requested as confirmation of receipt of documents.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Rebecca HedgecockTELEPHONE: (619) 241-0535
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
FACILITY NUMBER: 374604351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2021
Section Cited

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Limitations - Capacity and Ambulatory Status: A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time...
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This requirement is not met as evidenced by: Based on observation and records reviewed, licensee admitted a 7th (seventh) resident exceeding the license’s maximum number of six (6) residents in care. This poses an immediate safety risk to residents in care.
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Immediate $500 civil penalty is being accessed at today’s visit. A civil penalty of $100 per day will be accessed until POC is corrected.
Type A
03/03/2021
Section Cited

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Incidental Medical and Dental Care:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement is not met as evidenced by: Based on 2/24/21 observation, licensee left keys in lock of medication cabinets making medication accessible to residents in care. This poses an immediate safety risk to residents 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: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Rebecca HedgecockTELEPHONE: (619) 241-0535
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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
FACILITY NUMBER: 374604351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2021
Section Cited

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Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia:(1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)... cleaning supplies and disinfectants.
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This requirement is not met as evidenced by: Based on observation on 2/24/21, 2 knives, cleaning chemical and paints were unlocked and accessible to residents in care. This poses an immediate safety risk to Dementia residents 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: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Rebecca HedgecockTELEPHONE: (619) 241-0535
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4