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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604431
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:00:31 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 IIIFACILITY NUMBER:
374604431
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:9414 GROSSMONT BLVDTELEPHONE:
(818) 284-2502
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:6CENSUS: DATE:
11/15/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Anna PetrosyanTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Ramon Serrano, conducted an announced Pre-Licensing inspection. LPA met with Administrator (ADM) Anna Petrosyan and we discussed the purpose of the visit.

LPA conducted a tour of the facility, both inside and outside. There are no pools on site. The smoke and carbon monoxide alarms were present. Toilets intended for client use were operating as intended, and bathing facilities were observed to be clean and kempt. The windows, blinds and paint throughout the facility, was observed in good condition. Each room intended for client use had the appropriate furniture, bedding and appropriate lighting. ADM Anna stated there are no firearms stored on the premises.

Hot water temperature was measured in the facility at 107.1 degrees F. The ambient temperature inside the facility was measured at 70 degrees F. The facility was observed to be clean and kempt with no strong malodors. The refrigerators and freezers were observed to be clean and operational, with an ample amount of food to meet client needs. Cleaning solutions were also properly secured in the kitchen area.

The Component III portion of the application process was completed with ADM Anna on today's date as well.

Pre-Licensing is complete and this facility has no deficiencies. An exit interview was conducted. The Applicant will be provided a copy of their Appeal/Licensee rights (LIC9058 01/16). An electronic read receipt will serve as confirmation of receipt of documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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