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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604431
Report Date: 07/14/2022
Date Signed: 07/14/2022 10:34:47 AM


Document Has Been Signed on 07/14/2022 10:34 AM - 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 IIIFACILITY NUMBER:
374604431
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:9414 GROSSMONT BLVDTELEPHONE:
(818) 284-2502
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:6CENSUS: 6DATE:
07/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver Zulma Rodriguez, TIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Vicky Williamson conducted a case management visit to amend a Facility Report (LIC 809 D) that was generated and left at the facility on 7/11/22. LPA was granted entry into the facility by Caregiver Zulma Rodriguez, and discussed the purpose of the visit.

An exit interview was conducted with Caregiver Zulma Rodriguez and a copy of this report, amended LIC 809Ds, and Licensee Appeal Rights (LIC 9058) have been provided to Zulma Rodriguez.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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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