374604424-11-7-2023-08-AS-SJAB-CY3QJW-20231130111324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604424
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:59:06 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
11/02/2023 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20231102153802

FACILITY NAME:	SENIOR LIVING NORWOODS HACIENDA II		FACILITY NUMBER:	374604424
ADMINISTRATOR:	PETROSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	4146 ROLANDO AVE		TELEPHONE:	(619) 510-4930
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	6	CENSUS: 5	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Jonthan Torres, House Manager		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility failed to obtain the required liability insurance

INVESTIGATION FINDINGS:

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Licensing Program Analyst's (LPA's) Amy Domingo and Renita Hall conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation. LPA's were allowed entry by Jonthan Torrez, House Manager. LPA's identified themselves and disclosed the purpose of the visit and elements of the complaint with Jonthan Torres, House Manager and Linet Manasyan Administrator via phone call.

On November 2, 2023, the Department received a formal complaint about the absence of liability insurance for Senior Living Norwoods Hacienda. The facility is legally obligated to maintain liability insurance per Health and Safety Code 1569.605: Liability insurance coverage.

Continue on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231102153802

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 II	FACILITY NUMBER: 374604424
	VISIT DATE: 11/07/2023

NARRATIVE

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Continued from LIC9099

The investigation was conducted to assess the validity of the complaint. After a review of records, and interview with outside sources, it was found that that the facility did not possess the required liability insurance coverage for one month (August 2023) due to non-payment).

Based on review of records, the preponderance of evidence standard has been met, therefore the allegation that: the facility failed to obtain the required liability insurance is found to be SUBSTANTIATED.

An exit interview was conducted with the House Manager Jonthan Torres. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Manager and her signature on this report confirms receipt of the Licensee Rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20231102153802

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 II	FACILITY NUMBER: 374604424
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/07/2023 Section Cited HSC 1569.605	1 2 3 4 5 6 7	On and after July 1, 2015, all residential care facilities for the elderly,.... shall mainintain liability insurance.... caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees	1 2 3 4 5 6 7	Licensee to provide proof of Facility Liability Insurance is maintained and submitted to the Department as required. Plan of correction completed on 11/07/2023.
	8 9 10 11 12 13 14	The licensee did not ensure there was no lapse in Liability insurance. This requirement was not met as evidence by: Based upon interviews and records reviewed. This deficiency may pose a potiential Health and Safety risks to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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