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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604351
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:22:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2022 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20221206160611
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: 6DATE:
07/07/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jonathan Torres House ManagerTIME COMPLETED:
11:55 PM
ALLEGATION(S):
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Licensee did not meet resident's needs
Licensee did not issue refund, as required
Licensee did not safeguard resident's personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with House Manager Johnathan Cruz and spoke to Administrator Linet Manasya.

The Department’s investigation consisted of staff and outside source interviews. The investigation also included a facility and outside source records review. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff and outside sources.

It was alleged that resident's needs were not being met. Interview with Outside source (OS1), (See LIC811 Confidential Names list), revealed that resident 1 (R1) was admitted to the facility without signing an

(Continue on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 08-AS-20221206160611
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SENIOR LIVING NORWOODS HACIENDA
FACILITY NUMBER: 374604351
VISIT DATE: 07/07/2023
NARRATIVE
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(Continued from LIC9099)

LPA Domingo interviewed Staff 1 (S1) and S1 confirmed that there are no documents of a preadmission appraisal was conducted prior to admission. LPA Domingo requested to review R1's records or chart of R1 and S1 was unable to provide any records or documents that would indicate the needs of R1. S1 stated that there were no records for R1. LPA Domingo reviewed Resident 2 (R2), Resident 3 (R3) and Resident 4 (R4) records and the resident's records were complete with the required documentation.

It was alleged facility staff did not issue a refund after the discharge and removal of Resident 1 (R1) personal belongings. R1 was admitted to the facility on 09/03/2021 and was discharged on 09/05/2021. An interview with OS1 revealed that a full 30-day payment for rent was left at the facility as requested by S1. LPA Domingo requested from the facility staff financial records or a receipt of payment for R1. S1 stated that there were no documents or receipt of the advance payment. Records reviewed verified that the advanced payment was collected. Per Title 22 code of regulations and Health and Safety code all fees paid for after the death of a resident and removal of personal belongings shall be refunded.

It was alleged that the facility staff did not safeguard resident's personal property. Interviews with facility staff and outside source could not provide an inventory of personal belongings for R1. R1 was at the facility from 09/03/2021 through 09/05/2021 and the facility did not have any records for R1's three day stay at the facility.

Based on LPA's interviews with staff, outside source interviews, and record reviewed there is a preponderance of evidence to prove alleged violations occurred, therefore the allegation is substantiated. A substantiated finding means the allegations are valid because the preponderance of evidence standard has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on the LIC 9099-D.

An exit interview was conducted with House Manager Jonathan , to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20221206160611
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SENIOR LIVING NORWOODS HACIENDA
FACILITY NUMBER: 374604351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2023
Section Cited
CCR
87457c
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87457c Pre-Admission Appraisal: Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations....
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Licensee will conduct additional training in Pre-Admission Appraisal requirements to all staff including licensee by a third party provider. Licensee will submit training records to CCL with completed training on or before POC date of 08/07/2023.
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Based on interviews and records review, the facility did not obtain sufficient information regarding the care R1 needed for 1 out of 5 residents in care. This posed a potential safety risk to 1 of 5 of residents in care.
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Type B
08/07/2023
Section Cited
HSC
1569.652C
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Health and Safety Code section 1569.652 c) A refund of any fees paid in advance covering the time after the residents' personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or ….
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Licensee agrees to refund the balance of $5,250.00 by POC Date 08/07/20223 Licensee and Facility staff will also attend an on-line CDSS certified course on Title 22 refund regulations.
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Based on interviews and records reviews the Licensee did not issue a refund upon R1’s discharge from the facility. This poses a potential personal right violation to 1 out of 5 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: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20221206160611
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SENIOR LIVING NORWOODS HACIENDA
FACILITY NUMBER: 374604351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
87218(d)
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87218 Theft and Loss (d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly. or resident's representative, and dated
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Licensee will conduct additional training in Personal Property Inventoryrequirements to all staff including licensee by a third party provider. Licensee will submit training records to CCL with completed training on or before POC date of 08/07/2023.
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Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident's behalf….
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Type B
07/07/2023
Section Cited
CCR
87218(d)
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Based on interviews and review of records, the licensee did not complete an initial personal property inventory, which potentially violated the operating requirements of 1 out of 5 residents.
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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: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4