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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604431
Report Date: 07/22/2022
Date Signed: 07/22/2022 12:18:04 PM


Document Has Been Signed on 07/22/2022 12:18 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:
07/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Caregiver Zulma RodriguezTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced plan of correction visit to review documents from deficiencies cited on 7/11/22. LPA Williamson identified herself and was granted entry by Caregiver Zulma Rodriguez, to whom she discussed the purpose of the visit.

During today’s visit, LPA briefly toured the facility and obtained a copy of the Roster of Residents. Due to a personal reasons, Licensee was granted an extension for staff record review until 7/26/22. Plan of correction for Roster of Residents cleared during the visit. No deficiencies were cited during today’s visit.

An exit interview was conducted with Caregiver Zulma Rodriguez, and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) was provided to Caregiver.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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