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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604351
Report Date: 11/28/2023
Date Signed: 11/28/2023 01:08:29 PM


Document Has Been Signed on 11/28/2023 01:08 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:
11/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver Steve Estrada and Interim House Manager Rosie BebekyanTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Steve Estrada. LPA also met with Interim House Manager Rosie Bebekyan, who arrived later during the visit.

During today's visit, LPA briefly toured the facility and performed a health and safety welfare check on residents in care. LPA interviewed relevant staff and collected copies of pertinent care and administrative records. LPA also observed storage areas used for food and incontinence supplies.

During records review, LPA observed that Licensee did not possess an LIC602 Physician's Report or equivalent medical assessment as part of their written care records for Resident #1 (R1) and Resident #2 (R2). [See LIC811 Confidential Names List for a description of person identifiers used.] One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Bedekyan, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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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Document Has Been Signed on 11/28/2023 01:08 PM - It Cannot Be Edited

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: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
87458(a)

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87458 Medical Assessment: “(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.”
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Licensee agreed to coordinate with physician to obtain a current LIC602 Physician’s Report for R1 and R2, respectively. Licensee agreed to E-mail a copy of R1 and R2’s respective LIC602s to LPA by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, for 2 of 5 residents (R1 and R2), prior to their acceptance as a resident, licensee did not obtain and keep on file, documentation of a medical assessment, signed by a physician, which posed a potential health, safety, and personal rights risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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