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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604431
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:12:02 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 Renita Hall
COMPLAINT CONTROL NUMBER: 08-AS-20231102154107
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: 4DATE:
11/07/2023
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Wendy Gomez, CaregiverTIME COMPLETED:
02:15 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 the caregiver, Wendy Gomez . LPA's identified themselves and disclosed the purpose of the visit and elements of the complaint with Wendy Gomez, caregiver 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.

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.

Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (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)
Page: 1 of 3
Control Number 08-AS-20231102154107
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 III
FACILITY NUMBER: 374604431
VISIT DATE: 11/07/2023
NARRATIVE
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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 Wendy Gomez, Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver and her signature on this report confirms receipt of the Licensee Rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (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-20231102154107
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 III
FACILITY NUMBER: 374604431
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
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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
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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
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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.
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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: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (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)
Page: 3 of 3