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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604424
Report Date: 02/27/2024
Date Signed: 02/27/2024 05:02:17 PM


Document Has Been Signed on 02/27/2024 05:02 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 HACIENDA IIFACILITY NUMBER:
374604424
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:4146 ROLANDO AVETELEPHONE:
(619) 510-4930
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:6CENSUS: 6DATE:
02/27/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Caregiver Dana VegaTIME COMPLETED:
05:15 PM
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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 Dana Vega.

LPA briefly toured the facility and performed a health and safety welfare check on residents in care, finding no safety concerns. LPA also interviewed staff and residents.

No deficiencies were observed or cited on this date.

An exit interview was conducted with Vega. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to the Licensee during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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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