374604431-11-7-2023-08-AS-DPOL-CY325R-20231129160558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604431
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:19:27 PM

Unsubstantiated

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
05/26/2023 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20230526135543

FACILITY NAME:	SENIOR LIVING NORWOODS HACIENDA III		FACILITY NUMBER:	374604431
ADMINISTRATOR:	PETROSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	9414 GROSSMONT BLVD		TELEPHONE:	(818) 284-2502
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY:	6	CENSUS: 4	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	02:14 PM
MET WITH:	Wendy Gomez, Caregiver		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff pushed resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by the Wendy Gomez, Caregiver. LPA identified herself and disclosed the purpose of the visit and elements of the findings with Wendy Gomez, Caregiver.

The Department investigated the above listed complaint allegation. The investigation consisted of a tour of the facility, interviews with staff, residents, and records review.

On June 1, 2023, residents interview stated that they liked being at the facility and the staff were nice, "no one pushing anyone around." Staff interviewed stated that they had not witnessed or heard of any employee "pushing around" physically or verbally residents. The outside sources interviewed stated that the information given was vague and no physical bruises were noted on resident.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (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)

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Control Number 08-AS-20230526135543

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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There was insufficient evidence found to support the allegation that staff were "pushing around" resident. Due to a lack of evidence, the allegation is deemed to be unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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 Wendy Gomez and her signature on this report confirms receipt of the Licensee Rights.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (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)

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