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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604431
Report Date: 10/18/2023
Date Signed: 10/18/2023 01:04:30 PM


Document Has Been Signed on 10/18/2023 01:04 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
SAN DIEGO RO, 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: 4DATE:
10/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Wendy GomezTIME COMPLETED:
01:14 PM
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Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced case management visit regarding the health and safety of residents. LPA introduced himself and discussed the purpose of the visit with Caregiver Wendy Gomez.

LPA conducted a health and safety visit and obtained facility records.

Based on today’s visit no deficiencies were cited.

An exit interview was conducted with Wendy Gomez to whom a copy of this report, along with the Licensee Rights (03/22) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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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