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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604351
Report Date: 03/16/2021
Date Signed: 03/16/2021 06:51:31 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: 6DATE:
03/16/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Lissette AlcarazTIME COMPLETED:
02:15 PM
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Licensing Program Manager (LPM) Rebecca Hedgecock made an unannounced visit to the facility to conduct a Plan of Correction (POC) visit to confirm that the citations issued on March 2, 2021 have been corrected. LPM was greeted and granted entry by Lissette Alcaraz, Staff, and the purpose of today's visit was discussed. Both Licensee, Linet Manasyan and Administrator, Anna Petrosyan, were contacted via telephone.

The following citations were reviewed during today's visit:

87204(a) Limitations - Capacity and Ambulatory Status: As of March 9, 2021 a total of six (6) residents reside at the facility. R1 (see LIC 811 for confidential list of names) passed away the evening of March 8, 2021. During the visit, LPA toured the facility and observed six (6) residents in care .Civil penalty of $100 a day from March 3-9, 2021 is being assessed today for a total of $600. No further civil penalties will be accessed. Citation is being cleared.

87465(h)(2) Incidental Medical and Dental Care: On March 3, 2021, Administrator provided proof of training. Citation is being cleared.

87705(f)(1-2) Care of Persons with Dementia: On March 3, 2021, Administrator provided proof that paints were removed from property. However on today's visit, paints and cleaning chemical were observed to be placed in an unlock storage room within the facility to which staff did not have a key. Cleaning solvents under kitchen sink were also unlock. Lock was in disrepair. Civil penalties of $100 a day from March 3, 2021 to March 16, 2021 is being accessed at today's visit for a total of $1300. Civil penalties of $100 a day to incur until deficiency is corrected.

This report was discussed with both Licensee and Administrator. Licensee will be provided a copy of their appeal rights (LIC9058 01/16), along with a copy of this report ,LIC 421IM and LIC 421FC 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: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
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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