374604424-9-13-2021-08-AS-DNGN-C6TTQE-20210913145550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604424
Report Date: 09/13/2021
Date Signed: 09/13/2021 02:56:18 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 HACIENDA II		FACILITY NUMBER:	374604424
ADMINISTRATOR:	PETROSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	4146 ROLANDO AVE		TELEPHONE:	(818) 858-7543
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	6	CENSUS: 0	DATE:	09/13/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Applicant Anna Petrosyan and Administrator Linet Manasyan		TIME COMPLETED:	01:00 PM

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 Analysts (LPA) Dang Nguyen and Rebecca Ruiz conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. LPAs were greeted by, identified themselves to, and explained the purpose of the visit to Applicant Anna Petrosyan and Administrator Linet Manasyan. The facility fire clearance was granted on August 18, 2021 and reflects that the facility is approved for six (6) residents, of which four (4) may be non-ambulatory and one (1) may be bedridden. During today’s visit, LPAs accompanied by Petrosyan and Manasyan, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 78 degrees F. Water temperature in the two shared resident bathrooms was 115 degrees F and 109.2 degrees F, respectively. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

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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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 II	FACILITY NUMBER: 374604424
	VISIT DATE: 09/13/2021

NARRATIVE

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[CONTINUED FROM LIC 809]

The facility has enough linens, hygiene supplies, dining supplies, and food for future resident use. Refrigerator temperature was 36 degrees F, and freezer temperature was 0 degrees F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all operational. Two (2) operable fire extinguishers and one (1) complete first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. The applicant passed the pre-licensing inspection. LPAs also provided the Component III Training during today’s visit. Petrosyan was advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicant, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC809 (FAS) - (06/04)

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