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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604431
Report Date: 07/11/2022
Date Signed: 07/11/2022 05:20:19 PM

Document Has Been Signed on 07/11/2022 05:20 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 IIIFACILITY NUMBER:
374604431
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:9414 GROSSMONT BLVDTELEPHONE:
(818) 284-2502
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 6CENSUS: 6DATE:
07/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Caregiver Jonathan TorresTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vicky Williamson conducted a case management visit to cite for deficiencies observed during a complaint visit on 7/8/22. LPA requested case files for Caregiver Jonathan Torres (S1) and Caregiver Valeria Garcia (S2) during the visit due to both staff names were not listed on the Community Care Licensing Agency’s Facility Personnel Report Summary. LPA was unable to review records for S1 and S2 to verify that staff have required documentation. There were no records present at the facility for S1 and S2. S1 stated that he is associated to Senior Living Norwoods Hacienda (374604092). LPA spoke with S1 and Linet Maysayn, Licensee during a complaint investigation visit on 5/16/22 regarding S1’s association. LPA and Licensee discussed associating S1 to the facility, and Licensee agreed to make the correction. Caregiver Jonathan Torress was also present at the facility today (7/11/22).

On 7/8/2022, LPA observed S2 working at the facility without a criminal record clearance. S2 began working at the facility on 7/6/22. S2 stated she had completed a fingerprint clearance. S2 provided LPA with her name and date of birth; however, she was unable to provide her social security number. LPA was unable to verify the criminal record background clearance for S2.

LPA has made multiple attempts to obtain a copy of the Register of Residents from the facility staff via visit and email, however the document has not been submitted to Community Care Licensing.

Anna Petrosyan, Administrator and Linet Manasyan, Licensee were not present at the facility and unavailable by phone on 7/8/22 and 7/11/2022. On 7/10/22, LPA contacted Anna Petrosyan, to advise her that Valeria Garcia is not allowed to work at the facility until she has completed a fingerprint clearance.

The following deficiencies and civil penalties have been cited per Title 22, Division 6 of the California Code of Regulations (See LIC 809D and LIC 421BG).
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 374604431
VISIT DATE: 07/11/2022
NARRATIVE
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An exit interview was conducted with Caregiver Jonathan Torres and a copy of this report, LIC 809D, LIC 421BGs, and Licensee Appeal Rights (LIC 9058) have been provided to Caregiver Jonathan Torres.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
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Document Has Been Signed on 07/14/2022 10:38 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/12/2022 11:06 AM


Created By: Vicky Williamson On 07/11/2022 at 03:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 374604431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited
CCR
87355(e)(1)

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87355 (e)(1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing ... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
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Licensee will assure that Valerie Garcia immediately completes fingerprints clearance via Live Scan by POC date. Licensee understands that Valeria Garcia is not allowed to work at the facility.

A $300 Civil Penalty was assessed.
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The requirement was not met as evidenced by: Based on LPA observation, Valeria Garcia was observed working at the facility on 7/8/22 as a caregiver without a criminal record clearance.
This poses an immediate health and safety risk to residents in care.

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Type A
07/15/2022
Section Cited
CCR87355(e)(2)

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87355 (e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing ... in a licensed facility: Request a transfer of a criminal record clearance ... in Section 87355(c) or The requirement was not met as evidenced by:
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Licensee will assure that Jonathan Torres is only allowed to work at Senior Living Norwoods Hacienda #374604092, until fingerprints association has been completed. A $200 Civil Penalty was assessed.
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Based on LPA’s observation, Jonathan Torres was observed working at the facility on 5/16/22, 7/8/22 & 7/11/22. Jonathan Torres is fingerprint cleared; however, he has not been associated to the facility.
This poses an immediate health and safety risk to residents in care.

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This is an amended version of the original report left at the facility on 7/11/2022.
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
LICENSING EVALUATOR NAME:Vicky Williamson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2022 10:37 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/12/2022 11:04 AM


Created By: Vicky Williamson On 07/11/2022 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 374604431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2022
Section Cited
CCR
87412(a)

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87412 (a) Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee…

The requirement was not met as evidenced by: Based on record review, Licensee did not
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Licensee will complete all staff files by POC date. LPA will conduct a Case Management visit to review case files.
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maintain staff records for S1 and S2. S1 acknowledged that there were no staff records available for review during the time of the visit on 7/8/22.

The poses a potential health and safety risk to residents in care.
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Type B
07/18/2022
Section Cited
CCR87508(b)

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87508 (b) Register of Residents Registers of residents shall be available to the licensing agency to inspect, ... and copy upon demand during normal business hours …

This requirement was not met as evidenced by: Based on record review, there was no
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Licensee will provide a Register of Residents by POC date and submit a copy to Licensing Program Analyst Vicky Williamson via email.
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Register of Residents available for review on 5/16/22 & 7/8/22. Licensee does not maintain a register of residents. This poses a potential health and safety risk to residents in care.
This is an amended version of the original report left at the facility on 7/11/2022.
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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:Simon Jacob
LICENSING EVALUATOR NAME:Vicky Williamson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


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